AI – List

There is insufficient evidence to recommend use of TS, DPD, or TP for monitoring response to therapy.

Prescribe

0.98

Surgeries performed with the intent to limit the venous outflow of the penis are not recommended.

Test

0.61

The Task Force recommends the following endpoints be considered for safety and risk assessment in future studies:Appearance of or change in hirsutism, acne, male pattern balding, clitoromegaly, and deepening of the voice.Cardiovascular and metabolic evaluation, with and without estrogen replacement, should include fasting lipid profiles, vascular reactivity, markers of insulin sensitivity, and markers of inflammation.Effects on the breast, with or without estrogen replacement, should be measured. Breast biopsy studies with in vitro markers of cell proliferation and apoptosis should be considered.Alterations in the endometrium with and without estrogen coadministrationAlterations in mood using validated instruments.

Test

0.99

Caregivers should be trained to assess neonates for pain using multidimensional tools.

Prepare

0.48

Caregivers should be trained to assess neonates for pain using multidimensional tools.

Educate/Counsel

0.21

Surveillance colonoscopy with multiple biopsy specimens should be performed every 1 to 2 years beginning after 8 to 10 years of disease.

Monitor

0.8

It is recommended that patients with a severe head injury receive an early tracheostomy.

Perform Therapeutic Procedure

0.23

It is recommended that patients with a severe head injury receive an early tracheostomy.

Prescribe

0.75

It is recommended that patients in whom discography is positive but in whom MR imaging evidence of disc degeneration is absent not be considered candidates for operative intervention.

Perform Therapeutic Procedure

0.98

The USPSTF recommends against routine screening for elevated blood lead levels in asymptomatic children aged 1 to 5 years who are at average risk .

Test

1

Provide or refer for psychotherapy .

Refer/Consult

0.35

Physicians should fully explain diagnosis, prognosis, and all treatment options to each patient.

Educate/Counsel

0.84

Focus on providing opportunities for societal participation in meaningful roles.

Prepare

0.55

Focus on providing opportunities for societal participation in meaningful roles.

Advocate

0.28

Brief cognitive assessment instruments that focus on limited aspects of cognitive function (i.e., Clock Drawing Test, Time and Change Test) may be considered when screening patients for dementia.

Test

1

Schools should be considered appropriate sites for the availability of condoms, because they contain large adolescent populations and may potentially provide a comprehensive array of related educational and health care resources.

Prepare

1

Nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen may be used as adjuncts to opioids in selected patients.

Prescribe

0.97

Use of unattended APAP to either initially determine pressures for fixed CPAP or for self-adjusting APAP treatment in CPAP-naïve patients is not currently established.

Programme providers should also ensure that support is available to enable the participation of parents who might otherwise find it difficult to access these programmes.

Prepare

1

For patients with systolic dysfunction (ejection fraction [EF] <40%) who have no contraindications:Aldosterone antagonist (low dose) for patients with rest dyspnea or with a history of rest dyspnea or for symptomatic patients who have suffered a recent myocardial infarction .

Prescribe

0.99

Specialized nutrition support (SNS) should be used in patients who cannot meet their nutrient requirements by oral intake.

Perform Therapeutic Procedure

0.99

Healthcare professionals should have an increased awareness of the possibility of the presence of otitis media with effusion in asymptomatic children.

Prepare

0.92

Currently, data available from class II studies do not provide sufficient evidence that routine MRI should be performed on all very low birth weight (VLBW) infants for whom results of screening cranial US are abnormal.

Test

1

A standing anteroposterior (AP) and a lateral view should be taken initially. A tangential view of the patella-femoral joint ("sunrise" view) and a standing posteroanterior (PA) view taken in 40 degrees of flexion can be useful.

Test

1

All patients with acute stroke should undergo brain scanning (computed tomography [CT] or magnetic resonance imaging [MRI]) as soon as possible preferably within 24 hours (GPP). A local protocol for more urgent scans should be made available.

Antibiotics prolong the latency period and improve perinatal outcome in patients with preterm PROM and should be administered according to one of several published protocols if expectant management is to be pursued prior to 35 weeks of gestation.

Prescribe

0.89

Transabdominal ultrasound may be used as a complementary examination if the uterus is significantly enlarged or a wider view of the pelvis or abdomen is required. Transabdominal ultrasound may also be used in the small proportion of women in whom it proves technically impossible to perform a transvaginal ultrasound.

Routine screening for IUGR in low-risk patients should comprise classical clinical monitoring techniques. Ultrasound evaluation of the fetus is appropriate in patients determined to be at high risk.

Monitor

0.97

The presence of maternal thyroid disease is important information for the pediatrician to have at the time of delivery.

Test

0.25

The presence of maternal thyroid disease is important information for the pediatrician to have at the time of delivery.

Educate/Counsel

0.72

Prophylaxis Based on Patient Stratification for RiskThe duration of the prophylaxis for thromboembolism should be individualized, depending on the need, medical condition, functional status, support services, and risk of the patient.

Prescribe

0.99

Pain response to therapy should not be used as the sole diagnostic indicator of the underlying etiology of an acute headache.

Conclude

0.91

Counsel obese and overweight women about the risks of weight cycling--repeated episodes of weight loss and gain--and the benefits of adopting long-term healthy eating habits.

Educate/Counsel

1

Critical Illness Patients with critical illnesses are at nutrition risk and should undergo nutrition screening to identify those who require formal nutrition assessment with development of a nutrition care plan.

Inquire

0.93

Educate caregivers to assist in their ability to care for the wanderer.

Prepare

0.26

Educate caregivers to assist in their ability to care for the wanderer.

Educate/Counsel

0.53

If thrombocytopenia is accompanied by other cytopenias or splenomegaly and is mild (>50,000 cells/mm3), hypersplenism caused by infectious causes or coincident liver disease should be suspected.

Conclude

0.99

Vision screening should be performed at the earliest possible age and at regular intervals during childhood as recommended by the American Academy of Pediatrics (AAP). The goal remains to eliminate preventable blindness and treatable visual disability.

Monitor

1

Previously Treated Patients with Intermediate- or High-Risk Chronic Lymphocytic Leukemia Fludarabine is an acceptable treatment option after failure of first-line therapy.Choice of treatment should be influenced by previously used regimens and patient preference.

Prescribe

1

Expand the delineation of disease manifestations, noninvasive tests, and the role of the liver biopsy, so that the application of current treatment practices may be refined.

Test

0.93

The U.S. Preventive Services Task Force concludes that the evidence is insufficient to recommend for or against routine clinical breast examination (CBE) alone to screen for breast cancer.

Test

1

Use either a transparent dressing or sterile gauze to cover the cannula site.

Prepare

0.51

Patients should be instructed in the correct use of glucose meters, including quality control. Comparison between SMBG and concurrent laboratory glucose analysis should be performed at regular intervals to evaluate the accuracy of patient results.

Monitor

0.81

It is recommended that a thorough history and physical examination including a detailed neurologic examination and developmental assessment be performed in children presenting with an apparent first, unprovoked seizures.

Test

0.99

Parental choice regarding management of the delivery and subsequent care of the infant should be respected within the limits of medical feasibility and appropriateness

Conclude

0.6

The USPSTF concludes that the evidence is insufficient to recommend for or against the routine use of human papillomavirus (HPV) testing as a primary screening test for cervical cancer.

Test

1

For patients with declining hemoglobin levels but less severe anemia (those with hemoglobin concentration < 12 g/dL but who never have fallen below 10 g/dL), the decision of whether to use epoetin immediately or to wait until hemoglobin levels fall closer to 10 g/dL should be determined by clinical circumstances. Red blood cell transfusion is also a therapeutic option when warranted by severe clinical conditions.

Conclude

0.59

For patients with declining hemoglobin levels but less severe anemia (those with hemoglobin concentration < 12 g/dL but who never have fallen below 10 g/dL), the decision of whether to use epoetin immediately or to wait until hemoglobin levels fall closer to 10 g/dL should be determined by clinical circumstances. Red blood cell transfusion is also a therapeutic option when warranted by severe clinical conditions.

Perform Therapeutic Procedure

0.4

Pediatricians can work locally, nationally, and internationally to help change cultural norms conducive to eating disorders and proactively to change media messages.

Advocate

1

If a patient has GFR <30 mL/min/1.73 m2, low-density lipoprotein (LDL) should be targeted to <100 mg/dL; non-high-density lipoprotein (HDL) cholesterol should be targeted to <130 mg/dL; and fasting triglycerides >500 mg/dL should be treated.

Prescribe

0.77

At present there is insufficient evidence to recommend gemcitabine combined with a taxane as first-line therapy for non-small cell lung cancer.

Prescribe

1

Nutrition Screening A procedure for periodic nutrition rescreening should be implemented.

Test

0.61

Protein Requirements Histidine is a conditionally essential amino acid for neonates and infants up to 6 months of age and should be specifically supplemented.

Prevent

0.71

Each parenteral nutrition formulation compounded should be inspected for signs of gross particulate contamination, discoloration, particulate formation, and phase separation at the time of compounding and before administration.

Perform Therapeutic Procedure

1

For individuals without symptoms or a history of cancer, the guideline developers recommend against the use of serial chest x-rays (CXRs) to screen for the presence of lung cancer.

Test

1

Diagnosis of Primary TumorIn patients with a central lesion who present with or without hemoptysis, sputum cytology (at least three specimens) is a reasonable first step (in centers with a formal program directed at the acquisition, handling, and interpretation of sputum samples) in the diagnostic workup.

Test

1

In patients with a positron-emission tomography (PET) scan that is positive in the mediastinum, confirmation should be obtained by an invasive test that allows sampling of the PET-positive nodes with a high sensitivity and a low FN rate. In general, mediastinoscopy is likely to be the best test.

Patients with stage IIIA (N2) lung cancer identified preoperatively have a relatively poor prognosis when treated with surgery as a single modality. Several small trials of induction chemotherapy have yielded conflicting results about its effect on survival. The relative roles of surgery and radiation therapy as the local treatment modality are also not clearly defined. Definitive treatment recommendations are difficult to make in this setting. Therefore, patients in this subset should be referred for multidisciplinary evaluation before embarking on definitive treatment.

Prescribe

0.93

Infants identified as having significant risk of caries or assessed to be within 1 of the risk groups listed in the original guideline document should be entered into an aggressive anticipatory guidance and intervention program provided by a dentist between 6 and 12 months of age.

Educate/Counsel

1

Prevention:Continue preventive measures even when a patient has a pressure ulcer to prevent additional pressure areas from developing.

Educate/Counsel

0.47

The USPSTF recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults.

Test

0.78

The USPSTF recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults.

Educate/Counsel

0.22

If PTLD has been detected, it is recommended that a contrast enhanced computed tomography (CT) be the modality of choice for further evaluation. Chest radiographs, ultrasound, CT, and magnetic resonance imaging (MRI) have been used to detect PTLD .

Test

1

If systemic hypertension persists on maximal therapy with calcium channel blockers, the following concomitant drug therapy should be considered.

Prescribe

1

Skin inspection should occur regularly; the frequency of inspections should be determined in response to changes in the individual's condition in relation to both deterioration or recovery.

Monitor

1

Recommend patients with wounds and LEAD seek care guided by a clinical wound expert.

Refer/Consult

0.6

Recommend patients with wounds and LEAD seek care guided by a clinical wound expert.

Perform Therapeutic Procedure

0.23

Evaluate the patient for the presence of risk factors for heart failure.

Test

0.46

Evaluate the patient for the presence of risk factors for heart failure.

Prescribe

0.49

School personnel involved in detection of head lice infestation should be appropriately trained. The importance and difficulty of correctly diagnosing an active head lice infestation should be acknowledged. Schools should examine any lice related policies they may have with this in mind.

Prepare

1

Buteyko Breathing Techniques may be helpful in reducing reliever use and improving quality of life, but this will involve a considerable cost to the patient.

Educate/Counsel

1

Use the bed only for sleeping (or sex).

Educate/Counsel

0.69

Develop a nursing plan tailored to the patient's presenting problem(s) and risk factors.

Inquire

0.25

Develop a nursing plan tailored to the patient's presenting problem(s) and risk factors.

Prepare

0.34

Develop a nursing plan tailored to the patient's presenting problem(s) and risk factors.

Educate/Counsel

0.24

Infants and children with eating disorders should receive an oromotor assessment by an occupational therapist, speech therapist, nurse, or physician with training in pediatric oromotor dysfunction.

Prepare

0.96

Patients with good PS (i.e., ECOG level 0 or 1) should be considered for a platinum-based chemotherapy regimen based on the survival advantage provided over best supportive care (BSC).

Patients with symptomatic brain metastases should be treated with dexamethasone, 16 mg/d, for 4 weeks during the course of whole-brain radiation therapy (WBRT); dexamethasone should then be rapidly tapered and discontinued.

Prescribe

1

Patients with lung cancer should have clear understandable information about their diagnosis, treatment, and possible outcomes. Patients and their families should be offered clear, full, prompt, and culturally appropriate information, preferably in both verbal and written form.

Educate/Counsel

1

Offer screening with FOBT every year combined with flexible sigmoidoscopy every 5 years. When both tests are performed, the FOBT should be done first.

Monitor

1

Opioids should be used for patients with OA or RA when other medications and nonpharmacologic interventions produce inadequate pain relief and the patientâ??s quality of life is affected by the pain. Morphine, oxycodone, hydrocodone, or other mu agonist opioids, as a single agent or combined with an NSAID or with acetaminophen, should be used for moderate to severe OA or RA pain that has not responded to other treatments. The use of codeine and propoxyphene should be avoided because of their side effects and limited analgesic effectiveness.

Prescribe

1

All patients should receive education on the importance of lifestyle changes (e.g., engaging in regular weight-bearing exercise, quitting smoking, avoiding excessive alcohol intake), as well as vitamin D and calcium supplementation.

Educate/Counsel

1

Practice settings need a policy with respect to providing and requesting advance notice when transferring or admitting clients between practice settings when special resources (e.g., surfaces) are required.

Prepare

1

Parents should be advised that home cardiorespiratory monitoring has not been proven to prevent sudden unexpected deaths in infants.

Educate/Counsel

0.93

Further treatment with efalizumab is not recommended in patients unless their psoriasis has responded adequately at 12 weeks .

Prescribe

1

To reduce the incidence and mortality rate of cervix cancer, effective screening and preventive strategy must be actively pursued, in addition to early detection of disease and effective therapy .

Prescribe

0.91

Serological screening for hepatitis B surface (HBs) antigen and antibody (HBs Ag, anti-HBs IgG) should be done within 6 months pre-vaccination for all, except newborns. Hepatitis B vaccinations, except for newborns, should be given at months 0, 1, and 6, and anti-HBs IgG should be checked within 3 months after the booster dose at month 6. For newborns, vaccinations are given at months 0, 1, and 5. Newborns of hepatitis B virusâ??infected mothers who are hepatitis B e antigen (HBeAg) positive should also be given hepatitis B immunoglobulin at birth.

Prevent

0.98

In anthracycline-naive patients, who would ordinarily be offered treatment with a single-agent anthracycline (doxorubicin or epirubicin) or an anthracycline in a standard combination, the following options are also reasonable:Treatment with single-agent docetaxel 100 mg/m2 over one hour every three weeks.Docetaxel or paclitaxel in combination with doxorubicin.

Prescribe

1

Patients should have adequate, accurate information regarding factors that influence HIV transmission and methods for reducing the risk for transmission to others, emphasizing that the most effective methods for preventing transmission are those that protect noninfected persons against exposure to HIV (e.g., sexual abstinence; consistent and correct use of condoms made of latex, polyurethane or other synthetic materials; and sex with only a partner of the same HIV serostatus). HIV-infected patients who engage in high-risk sexual practices (i.e., capable of resulting in HIV transmission) with persons of unknown or negative HIV serostatus should be counseled to use condoms consistently and correctly.

Educate/Counsel

1

Intra-oral devices are an appropriate therapy for snorers and for patients with mild OSAHS with normal daytime alertness.

Prescribe

0.99

The following recommendations are based primarily on consensus and expert opinion:In addition to health risks and benefits, patient counseling should include consideration of how oophorectomy may relate to the individual patient's body image, perceptions concerning sexuality, and personal feelings.

Educate/Counsel

1

High-dose PGE2 vaginal suppositories may be used in the management of intrauterine fetal demise in the second trimester of pregnancy.

Test

0.6

High-dose PGE2 vaginal suppositories may be used in the management of intrauterine fetal demise in the second trimester of pregnancy.

Prescribe

0.32

The treatment of choice for anovulatory uterine bleeding is medical therapy with oral contraceptives.

Prescribe

1

Laparoscopic myomectomy appears to be a safe and effective option for women with a small number of moderately sized uterine leiomyomas who do not desire future fertility. Further studies are necessary to evaluate the safety of this procedure for women planning pregnancy.

Prepare

1

Pregnant patients with a history of isolated venous thrombosis directly related to a transient, highly thrombogenic event (orthopedic trauma, complicated surgery) in whom an underlying thrombophilia has been excluded may be offered heparin prophylaxis or no prophylaxis during the antepartum period. However, they should be counseled that their risk of thromboembolism is likely to be higher than the normal population. Prophylactic warfarin should be offered for 6 weeks postpartum.

Prescribe

1

Alternatives for thromboprophylaxis for moderate-risk* patients undergoing gynecologic surgery include the following:Thigh-high graduated compression stockings placed intraoperatively and continued until the patient is fully ambulatoryPneumatic compression placed intraoperatively and continued until the patient is fully ambulatory.Unfractionated heparin (5,000 U) administered 2 hours before surgery and continued postoperatively every 8 hours until discharge.Low-molecular-weight heparin (dalteparin, 2,500 antifactor-Xa U, or enoxaparin, 40 mg) administered 12 hours before surgery and once a day postoperatively until discharge.

Prescribe

1

Luteal phase support with progesterone is of unproven efficacy.

Prescribe

0.74

Available evidence does not support a recommendation for or against moderate caloric restriction in obese women with gestational diabetes mellitus (GDM). However, if caloric restriction is used, the diet should be restricted by no more than 33% of calories.

Test

0.28

Available evidence does not support a recommendation for or against moderate caloric restriction in obese women with gestational diabetes mellitus (GDM). However, if caloric restriction is used, the diet should be restricted by no more than 33% of calories.

Educate/Counsel

0.34

Available evidence does not support a recommendation for or against moderate caloric restriction in obese women with gestational diabetes mellitus (GDM). However, if caloric restriction is used, the diet should be restricted by no more than 33% of calories.

Perform Therapeutic Procedure

0.32

Daily calcium supplementation has not been shown to prevent preeclampsia and, therefore, is not recommended.

Prescribe

0.99

Raloxifene is appropriate therapy for women with established osteoporosis to prevent osteoporotic fractures.

Prescribe

0.99

The best or initial treatment for hirsutism, ovulation induction, or prevention of long-term metabolic sequelae for women with PCOS is unknown. All of these conditions may benefit from lifestyle modification as initial treatment.

Prescribe

1

For women at or beyond 36 weeks of gestation with a first episode of HSV occurring during the current pregnancy, antiviral therapy should be considered.

Prescribe

1

Periconceptional folic acid supplementation is recommended because it has been shown to reduce the occurrence and recurrence of neural tube defects (NTDs).

Prescribe

1

Neuroimaging should be considered in children with an abnormal neurologic examination (e.g., focal findings, signs of increased intracranial pressure, significant alteration of consciousness), the co-existence of seizures, or both.

Test

1

Patients with disabling complex partial seizures, with or without secondarily generalized seizures, who have failed appropriate trials of first-line antiepileptic drugs should be considered for referral to an epilepsy surgery center, although criteria for failure of drug treatment have not been definitely established .

Refer/Consult

0.62

Patients with disabling complex partial seizures, with or without secondarily generalized seizures, who have failed appropriate trials of first-line antiepileptic drugs should be considered for referral to an epilepsy surgery center, although criteria for failure of drug treatment have not been definitely established .

Prescribe

0.38

The principles of stepped care should be followed for patients with alcohol problems and dependence.

Conclude

0.27

Pediatricians should create a variety of ways for children and families to serve as advisorsâ??as members of child or family advisory councils, committees, and task forces dealing with operational issues in hospitals, clinics, and office-based practices; as participants in quality improvement initiatives; as educators of staff and professionals in training; and as leaders or coleaders of peer support programs.

Advocate

1

Pediatricians should undertake assessment and improvement activities necessary to maximize their practices' effectiveness in immunizing children.

Prepare

1

Encourage public and private sources to direct funding toward research into effective strategies to prevent overweight and obesity and to maximize limited family and community resources to achieve healthful outcomes for youth.

Advocate

1

While use of granulocyte colony-stimulating factor shortens the duration of neutropenia and decreases the infection rate in these patients, no differences in disease control or survival have been detected.

Prescribe

0.99

Practitioners should follow the post-operative rehabilitation protocol recommended by the orthopaedic surgeon.

Perform Therapeutic Procedure

0.93

Lifestyle modifications may aid in the prevention of onychomycosis. Modifications consist of wearing properly fitting shoes, using shower shoes in community showers, washing feet daily with soap and water, wearing hosiery made of synthetic materials, and supplying manicurist with personal pedicure/manicure tools .

Educate/Counsel

1

The time to normalization of base deficit, lactate, and pHi is predictive of survival.

Prescribe

0.46

Females aged between 1 and 2 years presenting with fever without source should be considered at risk for having a urinary tract infection.

Test

0.95

An intravenous bolus followed by continuous-infusion proton-pump inhibitor is effective in decreasing rebleeding in patients who have undergone successful endoscopic therapy.

Prescribe

1

Intraoperatively, the endoscopic general surgeon should participate in positioning the patient and selecting the proper locations of the trocars. The endoscopic general surgeon is not only responsible for safe entry into either the peritoneum or the retroperitoneum but also must participate in safe dissection to expose the proper spinal anatomy. He/she should be immediately available throughout the entire operative procedure. At the conclusion of the procedure, the endoscopic surgeon is responsible for safely exiting the peritoneum or retroperitoneum and for closure of trocar sites. The endoscopic surgeon must be capable of recognizing and managing intraoperative laparoscopic complications.

Prepare

0.99

Premature ejaculation can be treated effectively with several serotonin reuptake inhibitors (SRIs) or with topical anesthetics. The optimal treatment choice should be based on both physician judgment and patient preference.

Prescribe

1

Although the available evidence suggests a lower VAP rate with passive humidification than with active humidification, other issues related to the use of passive humidifiers (resistance, dead space volume, airway occlusion risk) preclude a recommendation for the general use of these devices. The decision to use a passive humidifier should not be based solely on infection control considerations.

Perform Therapeutic Procedure

0.96

Autologous transplantation is recommended for patients with advanced-stage myeloma and good performance status. The evidence is strongest for patients under 65 years of age without significant renal dysfunction following hydration and remission-induction chemotherapy. Physicians must use their clinical judgment in recommending transplantation to patients over 65 years of age or those with renal impairment.

Prescribe

1

Abdominal paracentesis should be performed and ascitic fluid should be obtained from inpatients and outpatients with clinically apparent new-onset ascites .

Test

0.88

The USPSTF recommends against routine screening of asymptomatic persons who are not at increased risk for syphilis infection.

Test

1

What are the standard initial treatment options?Recommendation: Bilateral orchiectomy or medical castration with luteinizing hormone releasing hormone (LHRH) agonists are the recommended initial treatments for metastatic prostate cancer. A full discussion between practitioner and patient should occur to determine which is best for the patient. Diethylstilbestrol (DES) should not be considered as a standard first-line treatment option and is currently no longer commercially available in North America.

Prescribe

1

Children and adolescents with newly diagnosed and/or recurrent malignancies should have their treatment coordinated by a board-certified pediatric hematologist/oncologist; treatment should be prescribed and initiated at a pediatric cancer center but may be continued at a center not specialized in the care of the pediatric oncology patient under the continuing oversight of the center's multidisciplinary team.

Refer/Consult

1

Roles of all the various mental health professionals who work on campus with students should be defined so that they are understood by students, families, all school staff members, and the mental health professionals themselves.

Prepare

1

On the basis of several consistent Class II and III studies, mitoxantrone probably reduces the clinical attack rate and reduces attack-related magnetic resonance imaging (MRI) outcomes in patients with relapsing MS (Type B recommendation). The potential toxicity of mitoxantrone, however, considerably limits its use in patients with relapsing forms of MS.

Prescribe

0.99

In patients with suspected PH, right-heart catheterization is required to confirm the presence of PH, establish the specific diagnosis, and determine the severity of PH.

Test

1

In adult patients with PAH and complex congenital heart disease who are undergoing transplantation, HLT is the procedure of choice.

Perform Therapeutic Procedure

0.78

Elevated mean right atrial pressure (mRAP).

Prescribe

0.57

Less common indications for splenectomy include splenic abscesses, cysts, sinistral portal hypertension secondary to isolated splenic vein thrombosis or obstruction, or splenic mass presumed to be a primary or undiagnosed neoplasm. Splenectomy is occasionally included in en bloc resection for malignancy in an adjacent organ, such as the stomach, colon, adrenal gland, or pancreas. Distal pancreatectomy usually includes splenectomy if preservation of the splenic artery and vein is either contraindicated (malignancy) or technically impossible.

Data concerning proper timing of office visits, CEA, and chest x-ray is insufficient to recommend one particular schedule of follow-up over another; however, office visits and CEA evaluations should be performed at a minimum of three times per year for the first two years of follow-up .

Monitor

1

Health practitioners should provide workers at risk of occupational asthma with health surveillance at least annually and more frequently in the first two years of exposure. ** SIGN C** SIGN 2+ Sensitisation and occupational asthma are most likely to develop in the first years of exposure for workers exposed to enzymes, complex platinum salts, isocyanates, and laboratory animal allergens.

Monitor

1

Diagnostic ultrasound should be undertaken by a radiologist with appropriate expertise.

Test

0.42

For patients with INRs of >9.0 and no significant bleeding, hold warfarin therapy and administer a higher dose of vitamin K1 (5 to 10 mg orally) with the expectation that the INR will be reduced substantially in 24 to 48 hours. Monitor the patient more frequently and use additional vitamin K1 if necessary. Resume therapy at a lower dose when INR is in the therapeutic range .

Prescribe

1

For patients with AF and prosthetic heart valves, the guideline developers recommend anticoagulation with an oral VKA, such as warfarin.

For patients with symptom duration <6 hours, the guideline developers recommend the administration of alteplase or tenecteplase over streptokinase .

Prescribe

1

For patients undergoing CABG who have no other indication for vitamin K antagonists (VKAs), the guideline developers suggest clinicians not administer VKAs .

Prescribe

1

In women with prosthetic heart valves at high risk, the guideline developers suggest the addition of low-dose aspirin, 75 to 162 mg/day.

Prescribe

1

Perform a renal ultrasound (or repeat the ultrasound if it was done prenatally). If the patient is found to have an abnormality of the urinary tract, continue monitoring for urinary tract infections and renal function.

Test

0.8

The primary care clinician should instruct patients and caregivers on how to maintain oral hygiene.

Educate/Counsel

0.5

The primary care clinician should instruct patients and caregivers on how to maintain oral hygiene.

Prescribe

0.32

Routine post-vaccination antibody measurement is not recommended because of the generally high efficacy of the vaccine.

Test

0.92

Refer the patient for further evaluation for suspected infection, positive probe to bone, and radiographic changes demonstrating Charcot osteoarthropathy.

Test

0.9

Begin planning for the transition to adulthood with the child and family as early as possible, but no later than 12 years of age.

Monitor

0.28

Begin planning for the transition to adulthood with the child and family as early as possible, but no later than 12 years of age.

Conclude

0.21

Begin planning for the transition to adulthood with the child and family as early as possible, but no later than 12 years of age.

Educate/Counsel

0.25

In patients who have a contraindication to the use of cisplatin or who experience serious toxicity from cisplatin and/or refuse treatment with cisplatin, the substitution of carboplatin for cisplatin in a taxane doublet regimen may be a reasonable treatment option.

Prescribe

1

Newborn screening systems should ensure parental and provider education and communication of screening results to primary-care providers in a manner that will ensure prompt referral to diagnostic centers.

Prepare

1

The recommended interval between oral health reviews should be determined specifically for each patient and tailored to meet his or her needs, on the basis of an assessment of disease levels and risk of or from dental disease.

Nurses should conduct a foot risk assessment for clients with known diabetes. This risk assessment includes the following:History of previous foot ulcersSensationStructural and biomechanical abnormalitiesCirculationSelf-care behaviour and knowledge

Test

1

Concern about increased new-onset diabetes among patients prescribed a thiazide-type diuretic with a beta-blocker means that this is not recommended as an initial combination for patients at raised risk of developing type II diabetes.

Prescribe

1

EEG should be used to support the classification of epileptic seizures and epilepsy syndromes when there is clinical doubt.

Test

0.99

Patients with persistent dysphagia should be reviewed regularly, at a frequency related to their individual swallowing function and dietary intake, by a professional skilled in the management of dysphagia.

Monitor

0.98

Patients with infected wounds require early and careful follow-up observation to ensure that the selected medical and surgical treatment regimens have been appropriate and effective .

Prepare

0.28

Patients with infected wounds require early and careful follow-up observation to ensure that the selected medical and surgical treatment regimens have been appropriate and effective .

Perform Therapeutic Procedure

0.5

The USPSTF makes no recommendation for or against screening for AAA in men aged 65 to 75 who have never smoked.

Test

1

Non-occupational PEP should not be prescribed when there is negligible or low risk of HIV transmission .

Prescribe

0.78

Ssubstance users who wish to stop using drugs should be referred to substance abuse treatment when indicated.

Refer/Consult

0.89

Sexual Assault Forensic Examiner (SAFE) who is trained to perform pediatric examinations should be included on the team whenever possible to assist in the medical examination, coordination of care, and discussions about treatment regimen. A rape crisis counselor and/or child advocacy team should be involved in all cases of sexual assault to assist the child and the family in dealing with the trauma and to assist with referrals.

Prepare

1

Pediatricians and pediatric subspecialty providers should lead by example by taking and teaching basic life support training courses.

Prepare

0.98

There is insufficient evidence at this time to make a recommendation regarding the use of continuous epidural infusion vs. intermittent injection in trauma patients.

Perform Therapeutic Procedure

0.57

There is insufficient evidence at this time to make a recommendation regarding the use of continuous epidural infusion vs. intermittent injection in trauma patients.

Prescribe

0.43

Pizotifen and nimodipine and clonidine did not show efficacy and are not recommended.

Prescribe

0.99

Prednisone has been demonstrated to have a beneficial effect on muscle strength and function in boys with Duchenne dystrophy (DD) and should be offered (at a dose of 0.75 mg/kg/day) as treatment .

Prescribe

0.99

Most women with one previous cesarean delivery with a low-transverse incision are candidates for vaginal birth after cesarean delivery (VBAC) and should be counseled about VBAC and offered a trial of labor.

Educate/Counsel

0.91

Obtain a history and perform a physical examination to identify medical illnesses, medications, allergies, and anatomic features that may affect procedural sedation and analgesia and airway management.No routine diagnostic testing is required before procedural sedation.

Inquire

0.82

Open and closed techniques for LIS seem to yield similar results.

Educate/Counsel

0.25

Open and closed techniques for LIS seem to yield similar results.

Perform Therapeutic Procedure

0.26

All youth entering a juvenile justice detention of correctional facility should be screened for mental or substance use disorders, suicide risk factors and behaviors, and other emotional or behavioral problems .

Test

1

The CTFPHC concludes that there is insufficient evidence to recommend treatment of IGT with metformin or acarbose to reduce the incidence of diabetes progression .

Prescribe

1

Screening for or treatment of asymptomatic bacteriuria is not recommended for the following persons.Premenopausal, nonpregnant women Diabetic women Older persons living in the community Elderly, institutionalized subjects Persons with spinal cord injury

Test

0.43

Screening for or treatment of asymptomatic bacteriuria is not recommended for the following persons.Premenopausal, nonpregnant women Diabetic women Older persons living in the community Elderly, institutionalized subjects Persons with spinal cord injury

Prescribe

0.57

Obtain a history of the client's incontinence.

Inquire

0.51

Nurses develop screening strategies and initial responses that respond to the needs of all women, taking into account differences based on race, ethnicity, class, religious/spiritual beliefs, age, ability, or sexual orientation.

Monitor

0.28

Nurses develop screening strategies and initial responses that respond to the needs of all women, taking into account differences based on race, ethnicity, class, religious/spiritual beliefs, age, ability, or sexual orientation.

Test

0.43

Nurses develop screening strategies and initial responses that respond to the needs of all women, taking into account differences based on race, ethnicity, class, religious/spiritual beliefs, age, ability, or sexual orientation.

Educate/Counsel

0.24

Parents should take a strong stand against the use of performance-enhancing substances and, whenever possible, demand that coaches be educated about the adversehealth effects of performance-enhancing substances.

Educate/Counsel

0.82

In patients with poor liver function, TIPS is preferred to surgical therapy in the prevention of rebleeding in patients who have failed medical therapy.

Perform Therapeutic Procedure

0.64

In patients with poor liver function, TIPS is preferred to surgical therapy in the prevention of rebleeding in patients who have failed medical therapy.

Prescribe

0.36

Nurses could consider the use of hip protectors to reduce hip fractures among those clients considered at high risk of fractures associated with falls; however, there is no evidence to support universal use of hip protectors among the elderly in health care settings.

Prescribe

1

With high-risk patients, evaluate and discuss the pros and cons of changing to a power wheelchair system as a way to prevent repetitive injuries.

Educate/Counsel

0.27

With high-risk patients, evaluate and discuss the pros and cons of changing to a power wheelchair system as a way to prevent repetitive injuries.

Prescribe

0.46

Erythropoietin is not recommended in situations where rapid (i.e., less than 4 weeks) recovery of hemoglobin is required.

Prescribe

0.94

Routine preoperative tests (i.e., tests intended to discover a disease or disorder in an asymptomatic patient) do not make an important contribution to the process of perioperative assessment and management of the patient by the anesthesiologist.

Test

0.98

Nurses will change all add-on devices a minimum of every 72 hours.

Prescribe

0.86

Hemorrhoidectomy should be reserved for patients refractory to office procedures or unable to tolerate office procedures, patients with large external hemorrhoids, or patients with combined internal and external hemorrhoids with significant prolapse.

Perform Therapeutic Procedure

1

Women should be advised that pregnancies have been reported in COC users taking non-liver enzyme-inducing antibiotics, but the evidence does not generally support reduced COC efficacy and causation.

Educate/Counsel

0.99

Assessment of pain in children with juvenile FMS (JFMS) should be developmentally based and should include both child and parent components. Include pain history, behavioral observation, physiologic cues, and evaluation of comorbid mood disorders, psychosocial distress, and functional status, including school attendance, for a comprehensive assessment.

Inquire

1

Public and private insurers should be responsible for payment of costs of MCV4, its administration to adolescents for whom MCV4 is recommended, and administrative costs involved in providing vaccines to high-risk people.

Prepare

1

Timed voiding/scheduled toileting is recommended throughout the whole day for patient who needs assistance in toileting.

Prescribe

0.65

Review assessment data together with the woman and identify the outcomes important to the woman and amenable to nursing intervention.

Educate/Counsel

1

Women should be informed that the failure rate of the LNG-IUS is similar to that of modern intrauterine devices (IUDs) .

Educate/Counsel

0.82

Liver transplantation for metastatic neuroendocrine tumors should be confined to highly selected patients who are not candidates for surgical resection in whom symptoms have persisted despite optimal medical therapy.

Perform Therapeutic Procedure

0.99

If a qualified provider does not meet with the patient at the time of the initial evaluation, the provider must see the patient sometime between presentation and closure.

Prepare

0.76

There are no current recommendations for tai chi related to insufficient evidence supporting its use.nying the rhythmical movements.

Perform Therapeutic Procedure

0.98

Clinicians should repeat CD4 or viral load results that are inconsistent with the clinical presentation before management decisions are made.

Test

0.63

Either primidone or propranolol may be used as initial therapy to treat limb tremor in ET.

Prescribe

1

Help ensure that all adolescents have knowledge of and access to contraception including barrier methods and emergency contraception supplies.

Prepare

0.95

Antibiotics are an unnecessary addition to routine incision and drainage of uncomplicated perianal abscesses.

Prescribe

0.77

Organizations should develop a plan for implementation that includes:An assessment of organizational readiness and barriers to education.Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process.Ongoing opportunities for discussion and education to reinforce the importance of best practices.Dedication of a qualified individual to provide the support needed for the education and implementation process.

Prepare

1

When assessing adherence, clinicians should use precise language that the patient can understand. In addition, clinicians should verify that patients are taking the medications as prescribed, specifically, correct medications, correct number of pills per dose, and correct number of doses per day.

Inquire

0.95

For patients undergoing elective total hip replacement (THR), the guideline developers recommend the routine use of one of the following three anticoagulants: (1) LMWH (at a usual high-risk dose, started 12 hours before surgery or 12 to 24 hours after surgery, or 4 to 6 hours after surgery at half the usual high-risk dose and then increasing to the usual high-risk dose the following day); (2) fondaparinux (2.5 mg started 6 to 8 hours after surgery); or (3) adjusted-dose vitamin K antagonist (VKA) started preoperatively or the evening after surgery (international normalized ratio [INR] target, 2.5; INR range, 2.0 to 3.0) .

Prescribe

1

In women with pathological stage III tumours, bone scanning, liver ultrasonography, and chest radiography are recommended postoperatively as part of baseline staging.

Test

1

If docetaxel and capecitabine are used in combination, the recommended starting dose for most patients is 950 mg/m2 twice daily of capecitabine (75% of full dose) on days 1 to 14 plus docetaxel 75 mg/m2 intravenously on day 1 of a 21-day cycle.

Prescribe

1

The review of raw data and the use of manual scoring for interpreting data from PM devices are recommended.

Conclude

0.52

Although published studies have evaluated yearly screening in conjunction with mammography, clinical breast examination, and in some cases, ultrasonography, the appropriate screening interval for MRIB is not yet determined.

Monitor

0.89

It is recommended that the child with OME who is at risk for developmental difficulties be aggressively managed as appropriate to his/her condition.

Educate/Counsel

0.4

It is recommended that the child with OME who is at risk for developmental difficulties be aggressively managed as appropriate to his/her condition.

Prescribe

0.31

Narcotic use must be carefully titrated and supervised.

Prescribe

0.6

GH treatment is indicated in children with documented GHD for correction of hypoglycemia and for induction of normal statural growth.

Prescribe

0.98

In patients with limited-stage small cell lung cancer, the addition of thoracic radiotherapy to standard combination chemotherapy improves both local control and overall survival and should be incorporated into a comprehensive treatment plan of combined modality therapy for limited-stage small cell lung cancer.

Prescribe

1

If CIN is identified at the margins of a diagnostic excisional procedure or in a postprocedure endocervical sampling, it is preferred that the 4- to 6-month follow-up visit include a colposcopic examination and an endocervical sampling .

Test

1

As an alternative to conventional cervical cytology smears, cervical screening may be performed every two years using liquid-based cytology; at or after age 30, women who have had three consecutive, technically satisfactory normal/negative cytology results may be screened every two to three years (unless they have a history of in utero DES exposure, are HIV+, or are immunocompromised).

Monitor

1

As an alternative to conventional cervical cytology smears, cervical screening may be performed every two years using liquid-based cytology; at or after age 30, women who have had three consecutive, technically satisfactory normal/negative cytology results may be screened every two to three years (unless they have a history of in utero DES exposure, are HIV+, or are immunocompromised).

Test

0.96

The Task Force recommends the following endpoints be considered for safety and risk assessment in future studies:Appearance of or change in hirsutism acne male pattern balding clitoromegaly and deepening of the voice. Cardiovascular and metabolic evaluation with and without estrogen replacement should include fasting lipid profiles vascular reactivity markers of insulin sensitivity and markers of inflammation. Effects on the breast with or without estrogen replacement should be measured. Breast biopsy studies with in vitro markers of cell proliferation and apoptosis should be considered.Alterations in the endometrium with and without estrogen coadministrationAlterations in mood using validated instruments.

Perform Therapeutic Procedure

0.98

It is recommended that patients in whom discography is positive but in whom MR imaging evidence of disc degeneration is absent not be considered candidates for operative intervention.

Educate/Counsel

0.84

Physicians should fully explain diagnosis prognosis and all treatment options to each patient.

Test

1

Brief cognitive assessment instruments that focus on limited aspects of cognitive function (i.e. Clock Drawing Test Time and Change Test) may be considered when screening patients for dementia.

Prepare

1

Schools should be considered appropriate sites for the availability of condoms because they contain large adolescent populations and may potentially provide a comprehensive array of related educational and health care resources.

Monitor

0.28

A focused exam of the hair and scalp should be performed.

Test

1

A standing anteroposterior (AP) and a lateral view should be taken initially. A tangential view of the patella-femoral joint ( sunrise view) and a standing posteroanterior (PA) view taken in 40 degrees of flexion can be useful.

Prescribe

0.94

Antibiotics prolong the latency period and improve perinatal outcome in patients with preterm PROM and should be administered according to one of several published protocols if expectant management is to be pursued prior to 35 weeks of gestation.

Prescribe

0.98

Prophylaxis Based on Patient Stratification for RiskThe duration of the prophylaxis for thromboembolism should be individualized depending on the need medical condition functional status support services and risk of the patient.

Educate/Counsel

1

Counsel obese and overweight women about the risks of weight cycling--repeated episodes of weight loss and gain--and the benefits of adopting long-term healthy eating habits.

Test

0.98

Critical Illness Patients with critical illnesses are at nutrition risk and should undergo nutrition screening to identify those who require formal nutrition assessment with development of a nutrition care plan.

Educate/Counsel

0.72

Educate caregivers to assist in their ability to care for the wanderer.

Prescribe

0.56

If thrombocytopenia is accompanied by other cytopenias or splenomegaly and is mild (>50 000 cells/mm3) hypersplenism caused by infectious causes or coincident liver disease should be suspected.

Prepare

0.86

Vision screening should be performed at the earliest possible age and at regular intervals during childhood as recommended by the American Academy of Pediatrics (AAP). The goal remains to eliminate preventable blindness and treatable visual disability.

Prescribe

1

Previously Treated Patients with Intermediate- or High-Risk Chronic Lymphocytic Leukemia Fludarabine is an acceptable treatment option after failure of first-line therapy.Choice of treatment should be influenced by previously used regimens and patient preference.

Test

0.83

Expand the delineation of disease manifestations noninvasive tests and the role of the liver biopsy so that the application of current treatment practices may be refined.

Monitor

0.36

Expand the delineation of disease manifestations noninvasive tests and the role of the liver biopsy so that the application of current treatment practices may be refined.

Educate/Counsel

0.64

Patients should be instructed in the correct use of glucose meters including quality control. Comparison between SMBG and concurrent laboratory glucose analysis should be performed at regular intervals to evaluate the accuracy of patient results.

Test

1

It is recommended that a thorough history and physical examination including a detailed neurologic examination and developmental assessment be performed in children presenting with an apparent first unprovoked seizures.

Conclude

0.78

Parental choice regarding management of the delivery and subsequent care of the infant should be respected within the limits of medical feasibility and appropriateness

Advocate

1

Pediatricians can work locally nationally and internationally to help change cultural norms conducive to eating disorders and proactively to change media messages.

Prescribe

1

Coordinate signing and sending sympathy card.

Prescribe

0.81

Protein Requirements Histidine is a conditionally essential amino acid for neonates and infants up to 6 months of age and should be specifically supplemented.

Perform Therapeutic Procedure

1

Each parenteral nutrition formulation compounded should be inspected for signs of gross particulate contamination discoloration particulate formation and phase separation at the time of compounding and before administration.

Test

1

Diagnosis of Primary TumorIn patients with a central lesion who present with or without hemoptysis sputum cytology (at least three specimens) is a reasonable first step (in centers with a formal program directed at the acquisition handling and interpretation of sputum samples) in the diagnostic workup.

Test

1

In patients with a positron-emission tomography (PET) scan that is positive in the mediastinum confirmation should be obtained by an invasive test that allows sampling of the PET-positive nodes with a high sensitivity and a low FN rate. In general mediastinoscopy is likely to be the best test.

Patients with stage IIIA (N2) lung cancer identified preoperatively have a relatively poor prognosis when treated with surgery as a single modality. Several small trials of induction chemotherapy have yielded conflicting results about its effect on survival. The relative roles of surgery and radiation therapy as the local treatment modality are also not clearly defined. Definitive treatment recommendations are difficult to make in this setting. Therefore patients in this subset should be referred for multidisciplinary evaluation before embarking on definitive treatment.

Educate/Counsel

1

The USPSTF recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults.

Test

1

If PTLD has been detected it is recommended that a contrast enhanced computed tomography (CT) be the modality of choice for further evaluation. Chest radiographs ultrasound CT and magnetic resonance imaging (MRI) have been used to detect PTLD .

Refer/Consult

0.76

Recommend patients with wounds and LEAD seek care guided by a clinical wound expert.

Prepare

1

School personnel involved in detection of head lice infestation should be appropriately trained. The importance and difficulty of correctly diagnosing an active head lice infestation should be acknowledged. Schools should examine any lice related policies they may have with this in mind.

Educate/Counsel

1

Buteyko Breathing Techniques may be helpful in reducing reliever use and improving quality of life but this will involve a considerable cost to the patient.

Test

0.24

Buteyko Breathing Techniques may be helpful in reducing reliever use and improving quality of life but this will involve a considerable cost to the patient.

Educate/Counsel

0.63

Develop a nursing plan tailored to the patient's presenting problem(s) and risk factors.

Test

0.67

Develop a nursing plan tailored to the patient's presenting problem(s) and risk factors.

Prepare

0.3

Infants and children with eating disorders should receive an oromotor assessment by an occupational therapist speech therapist nurse or physician with training in pediatric oromotor dysfunction.

Prescribe

1

Patients with symptomatic brain metastases should be treated with dexamethasone 16 mg/d for 4 weeks during the course of whole-brain radiation therapy (WBRT); dexamethasone should then be rapidly tapered and discontinued.

Educate/Counsel

1

Patients with lung cancer should have clear understandable information about their diagnosis treatment and possible outcomes. Patients and their families should be offered clear full prompt and culturally appropriate information preferably in both verbal and written form.

Prescribe

1

Opioids should be used for patients with OA or RA when other medications and nonpharmacologic interventions produce inadequate pain relief and the patient??s quality of life is affected by the pain. Morphine oxycodone hydrocodone or other mu agonist opioids as a single agent or combined with an NSAID or with acetaminophen should be used for moderate to severe OA or RA pain that has not responded to other treatments. The use of codeine and propoxyphene should be avoided because of their side effects and limited analgesic effectiveness.

Educate/Counsel

0.91

All patients should receive education on the importance of lifestyle changes (e.g. engaging in regular weight-bearing exercise quitting smoking avoiding excessive alcohol intake) as well as vitamin D and calcium supplementation.

Prepare

1

Practice settings need a policy with respect to providing and requesting advance notice when transferring or admitting clients between practice settings when special resources (e.g. surfaces) are required.

Prescribe

0.88

To reduce the incidence and mortality rate of cervix cancer effective screening and preventive strategy must be actively pursued in addition to early detection of disease and effective therapy .

Prevent

0.99

Serological screening for hepatitis B surface (HBs) antigen and antibody (HBs Ag anti-HBs IgG) should be done within 6 months pre-vaccination for all except newborns. Hepatitis B vaccinations except for newborns should be given at months 0 1 and 6 and anti-HBs IgG should be checked within 3 months after the booster dose at month 6. For newborns vaccinations are given at months 0 1 and 5. Newborns of hepatitis B virus??infected mothers who are hepatitis B e antigen (HBeAg) positive should also be given hepatitis B immunoglobulin at birth.

Prescribe

1

In anthracycline-naive patients who would ordinarily be offered treatment with a single-agent anthracycline (doxorubicin or epirubicin) or an anthracycline in a standard combination the following options are also reasonable:Treatment with single-agent docetaxel 100 mg/m2 over one hour every three weeks.Docetaxel or paclitaxel in combination with doxorubicin.

Educate/Counsel

1

Patients should have adequate accurate information regarding factors that influence HIV transmission and methods for reducing the risk for transmission to others emphasizing that the most effective methods for preventing transmission are those that protect noninfected persons against exposure to HIV (e.g. sexual abstinence; consistent and correct use of condoms made of latex polyurethane or other synthetic materials; and sex with only a partner of the same HIV serostatus). HIV-infected patients who engage in high-risk sexual practices (i.e. capable of resulting in HIV transmission) with persons of unknown or negative HIV serostatus should be counseled to use condoms consistently and correctly.

Prescribe

0.98

Intra-oral devices are an appropriate therapy for snorers and for patients with mild OSAHS with normal daytime alertness.

Educate/Counsel

1

The following recommendations are based primarily on consensus and expert opinion:In addition to health risks and benefits patient counseling should include consideration of how oophorectomy may relate to the individual patient's body image perceptions concerning sexuality and personal feelings.

Prepare

0.86

Laparoscopic myomectomy appears to be a safe and effective option for women with a small number of moderately sized uterine leiomyomas who do not desire future fertility. Further studies are necessary to evaluate the safety of this procedure for women planning pregnancy.

Prevent

0.93

Alternatives for thromboprophylaxis for moderate-risk* patients undergoing gynecologic surgery include the following:Thigh-high graduated compression stockings placed intraoperatively and continued until the patient is fully ambulatoryPneumatic compression placed intraoperatively and continued until the patient is fully ambulatory.Unfractionated heparin (5 000 U) administered 2 hours before surgery and continued postoperatively every 8 hours until discharge.Low-molecular-weight heparin (dalteparin 2 500 antifactor-Xa U or enoxaparin 40 mg) administered 12 hours before surgery and once a day postoperatively until discharge.

Prescribe

0.99

Daily calcium supplementation has not been shown to prevent preeclampsia and therefore is not recommended.

Prescribe

1

Periconceptional folic acid supplementation is recommended because it has been shown to reduce the occurrence and recurrence of neural tube defects (NTDs).

Prescribe

0.55

The principles of stepped care should be followed for patients with alcohol problems and dependence.

Advocate

1

Pediatricians should create a variety of ways for children and families to serve as advisors??as members of child or family advisory councils committees and task forces dealing with operational issues in hospitals clinics and office-based practices; as participants in quality improvement initiatives; as educators of staff and professionals in training; and as leaders or coleaders of peer support programs.

Prepare

0.99

Pediatricians should undertake assessment and improvement activities necessary to maximize their practices' effectiveness in immunizing children.

Advocate

1

Encourage public and private sources to direct funding toward research into effective strategies to prevent overweight and obesity and to maximize limited family and community resources to achieve healthful outcomes for youth.

Prescribe

1

While use of granulocyte colony-stimulating factor shortens the duration of neutropenia and decreases the infection rate in these patients no differences in disease control or survival have been detected.

Educate/Counsel

1

Lifestyle modifications may aid in the prevention of onychomycosis. Modifications consist of wearing properly fitting shoes using shower shoes in community showers washing feet daily with soap and water wearing hosiery made of synthetic materials and supplying manicurist with personal pedicure/manicure tools .

Conclude

0.48

Lifestyle modifications may aid in the prevention of onychomycosis. Modifications consist of wearing properly fitting shoes using shower shoes in community showers washing feet daily with soap and water wearing hosiery made of synthetic materials and supplying manicurist with personal pedicure/manicure tools .

Prescribe

0.25

The time to normalization of base deficit lactate and pHi is predictive of survival.

Test

0.95

Females aged between 1 and 2 years presenting with fever without source should be considered at risk for having a urinary tract infection.

Perform Therapeutic Procedure

1

Intraoperatively the endoscopic general surgeon should participate in positioning the patient and selecting the proper locations of the trocars. The endoscopic general surgeon is not only responsible for safe entry into either the peritoneum or the retroperitoneum but also must participate in safe dissection to expose the proper spinal anatomy. He/she should be immediately available throughout the entire operative procedure. At the conclusion of the procedure the endoscopic surgeon is responsible for safely exiting the peritoneum or retroperitoneum and for closure of trocar sites. The endoscopic surgeon must be capable of recognizing and managing intraoperative laparoscopic complications.

Prescribe

1

Autologous transplantation is recommended for patients with advanced-stage myeloma and good performance status. The evidence is strongest for patients under 65 years of age without significant renal dysfunction following hydration and remission-induction chemotherapy. Physicians must use their clinical judgment in recommending transplantation to patients over 65 years of age or those with renal impairment.

Test

0.7

Autologous transplantation is recommended for patients with advanced-stage myeloma and good performance status. The evidence is strongest for patients under 65 years of age without significant renal dysfunction following hydration and remission-induction chemotherapy. Physicians must use their clinical judgment in recommending transplantation to patients over 65 years of age or those with renal impairment.

Perform Therapeutic Procedure

0.3

Abdominal paracentesis should be performed and ascitic fluid should be obtained from inpatients and outpatients with clinically apparent new-onset ascites .

Prescribe

1

What are the standard initial treatment options?Recommendation: Bilateral orchiectomy or medical castration with luteinizing hormone releasing hormone (LHRH) agonists are the recommended initial treatments for metastatic prostate cancer. A full discussion between practitioner and patient should occur to determine which is best for the patient. Diethylstilbestrol (DES) should not be considered as a standard first-line treatment option and is currently no longer commercially available in North America.

Refer/Consult

1

Children and adolescents with newly diagnosed and/or recurrent malignancies should have their treatment coordinated by a board-certified pediatric hematologist/oncologist; treatment should be prescribed and initiated at a pediatric cancer center but may be continued at a center not specialized in the care of the pediatric oncology patient under the continuing oversight of the center's multidisciplinary team.

Prepare

1

Roles of all the various mental health professionals who work on campus with students should be defined so that they are understood by students families all school staff members and the mental health professionals themselves.

Test

1

On the basis of several consistent Class II and III studies mitoxantrone probably reduces the clinical attack rate and reduces attack-related magnetic resonance imaging (MRI) outcomes in patients with relapsing MS (Type B recommendation). The potential toxicity of mitoxantrone however considerably limits its use in patients with relapsing forms of MS.

Test

1

In patients with suspected PH right-heart catheterization is required to confirm the presence of PH establish the specific diagnosis and determine the severity of PH.

Perform Therapeutic Procedure

0.87

In adult patients with PAH and complex congenital heart disease who are undergoing transplantation HLT is the procedure of choice.

Perform Therapeutic Procedure

1

Less common indications for splenectomy include splenic abscesses cysts sinistral portal hypertension secondary to isolated splenic vein thrombosis or obstruction or splenic mass presumed to be a primary or undiagnosed neoplasm. Splenectomy is occasionally included in en bloc resection for malignancy in an adjacent organ such as the stomach colon adrenal gland or pancreas. Distal pancreatectomy usually includes splenectomy if preservation of the splenic artery and vein is either contraindicated (malignancy) or technically impossible.

Monitor

1

Data concerning proper timing of office visits CEA and chest x-ray is insufficient to recommend one particular schedule of follow-up over another; however office visits and CEA evaluations should be performed at a minimum of three times per year for the first two years of follow-up .

Monitor

1

Health practitioners should provide workers at risk of occupational asthma with health surveillance at least annually and more frequently in the first two years of exposure. ** SIGN C** SIGN 2+ Sensitisation and occupational asthma are most likely to develop in the first years of exposure for workers exposed to enzymes complex platinum salts isocyanates and laboratory animal allergens.

Prescribe

1

For patients with INRs of >9.0 and no significant bleeding hold warfarin therapy and administer a higher dose of vitamin K1 (5 to 10 mg orally) with the expectation that the INR will be reduced substantially in 24 to 48 hours. Monitor the patient more frequently and use additional vitamin K1 if necessary. Resume therapy at a lower dose when INR is in the therapeutic range .

Prescribe

1

For patients with AF and prosthetic heart valves the guideline developers recommend anticoagulation with an oral VKA such as warfarin.

Test

1

Perform a renal ultrasound (or repeat the ultrasound if it was done prenatally). If the patient is found to have an abnormality of the urinary tract continue monitoring for urinary tract infections and renal function.

Educate/Counsel

0.33

Perform a renal ultrasound (or repeat the ultrasound if it was done prenatally). If the patient is found to have an abnormality of the urinary tract continue monitoring for urinary tract infections and renal function.

Prescribe

0.49

The primary care clinician should instruct patients and caregivers on how to maintain oral hygiene.

Test

0.93

Refer the patient for further evaluation for suspected infection positive probe to bone and radiographic changes demonstrating Charcot osteoarthropathy.

Educate/Counsel

0.38

Refer the patient for further evaluation for suspected infection positive probe to bone and radiographic changes demonstrating Charcot osteoarthropathy.

Prescribe

0.32

Begin planning for the transition to adulthood with the child and family as early as possible but no later than 12 years of age.

Prescribe

1

In patients who have a contraindication to the use of cisplatin or who experience serious toxicity from cisplatin and/or refuse treatment with cisplatin the substitution of carboplatin for cisplatin in a taxane doublet regimen may be a reasonable treatment option.

Prepare

1

Newborn screening systems should ensure parental and provider education and communication of screening results to primary-care providers in a manner that will ensure prompt referral to diagnostic centers.

Monitor

0.9

The recommended interval between oral health reviews should be determined specifically for each patient and tailored to meet his or her needs on the basis of an assessment of disease levels and risk of or from dental disease.

Nurses should conduct a foot risk assessment for clients with known diabetes. This risk assessment includes the following:History of previous foot ulcersSensationStructural and biomechanical abnormalitiesCirculationSelf-care behaviour and knowledge

Test

0.96

EEG should be used to support the classification of epileptic seizures and epilepsy syndromes when there is clinical doubt.

Monitor

1

Patients with persistent dysphagia should be reviewed regularly at a frequency related to their individual swallowing function and dietary intake by a professional skilled in the management of dysphagia.

Perform Therapeutic Procedure

0.79

Patients with infected wounds require early and careful follow-up observation to ensure that the selected medical and surgical treatment regimens have been appropriate and effective .

Prepare

1

Sexual Assault Forensic Examiner (SAFE) who is trained to perform pediatric examinations should be included on the team whenever possible to assist in the medical examination coordination of care and discussions about treatment regimen. A rape crisis counselor and/or child advocacy team should be involved in all cases of sexual assault to assist the child and the family in dealing with the trauma and to assist with referrals.

Prepare

0.97

Pediatricians and pediatric subspecialty providers should lead by example by taking and teaching basic life support training courses.

Prescribe

0.98

Pizotifen and nimodipine and clonidine did not show efficacy and are not recommended.

Prescribe

1

Prednisone has been demonstrated to have a beneficial effect on muscle strength and function in boys with Duchenne dystrophy (DD) and should be offered (at a dose of 0.75 mg/kg/day) as treatment .

Educate/Counsel

0.92

Most women with one previous cesarean delivery with a low-transverse incision are candidates for vaginal birth after cesarean delivery (VBAC) and should be counseled about VBAC and offered a trial of labor.

Inquire

0.88

Obtain a history and perform a physical examination to identify medical illnesses medications allergies and anatomic features that may affect procedural sedation and analgesia and airway management.No routine diagnostic testing is required before procedural sedation.

Educate/Counsel

0.32

Open and closed techniques for LIS seem to yield similar results.

Test

1

All youth entering a juvenile justice detention of correctional facility should be screened for mental or substance use disorders suicide risk factors and behaviors and other emotional or behavioral problems .

Test

0.71

Nurses develop screening strategies and initial responses that respond to the needs of all women taking into account differences based on race ethnicity class religious/spiritual beliefs age ability or sexual orientation.

Educate/Counsel

0.9

Parents should take a strong stand against the use of performance-enhancing substances and whenever possible demand that coaches be educated about the adversehealth effects of performance-enhancing substances.

Educate/Counsel

0.99

With high-risk patients evaluate and discuss the pros and cons of changing to a power wheelchair system as a way to prevent repetitive injuries.

Test

1

Routine preoperative tests (i.e. tests intended to discover a disease or disorder in an asymptomatic patient) do not make an important contribution to the process of perioperative assessment and management of the patient by the anesthesiologist.

Perform Therapeutic Procedure

1

Hemorrhoidectomy should be reserved for patients refractory to office procedures or unable to tolerate office procedures patients with large external hemorrhoids or patients with combined internal and external hemorrhoids with significant prolapse.

Educate/Counsel

1

Women should be advised that pregnancies have been reported in COC users taking non-liver enzyme-inducing antibiotics but the evidence does not generally support reduced COC efficacy and causation.

Inquire

0.98

Assessment of pain in children with juvenile FMS (JFMS) should be developmentally based and should include both child and parent components. Include pain history behavioral observation physiologic cues and evaluation of comorbid mood disorders psychosocial distress and functional status including school attendance for a comprehensive assessment.

Prepare

1

Public and private insurers should be responsible for payment of costs of MCV4 its administration to adolescents for whom MCV4 is recommended and administrative costs involved in providing vaccines to high-risk people.

Educate/Counsel

0.94

Review assessment data together with the woman and identify the outcomes important to the woman and amenable to nursing intervention.

Perform Therapeutic Procedure

1

Liver transplantation for metastatic neuroendocrine tumors should be confined to highly selected patients who are not candidates for surgical resection in whom symptoms have persisted despite optimal medical therapy.

Prepare

0.58

If a qualified provider does not meet with the patient at the time of the initial evaluation the provider must see the patient sometime between presentation and closure.

Prepare

0.95

Help ensure that all adolescents have knowledge of and access to contraception including barrier methods and emergency contraception supplies.

Perform Therapeutic Procedure

0.38

Help ensure that all adolescents have knowledge of and access to contraception including barrier methods and emergency contraception supplies.

Prescribe

0.56

Antibiotics are an unnecessary addition to routine incision and drainage of uncomplicated perianal abscesses.

Prepare

1

Organizations should develop a plan for implementation that includes:An assessment of organizational readiness and barriers to education.Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process.Ongoing opportunities for discussion and education to reinforce the importance of best practices.Dedication of a qualified individual to provide the support needed for the education and implementation process.

Inquire

1

When assessing adherence clinicians should use precise language that the patient can understand. In addition clinicians should verify that patients are taking the medications as prescribed specifically correct medications correct number of pills per dose and correct number of doses per day.

Prescribe

1

For patients undergoing elective total hip replacement (THR) the guideline developers recommend the routine use of one of the following three anticoagulants: (1) LMWH (at a usual high-risk dose started 12 hours before surgery or 12 to 24 hours after surgery or 4 to 6 hours after surgery at half the usual high-risk dose and then increasing to the usual high-risk dose the following day); (2) fondaparinux (2.5 mg started 6 to 8 hours after surgery); or (3) adjusted-dose vitamin K antagonist (VKA) started preoperatively or the evening after surgery (international normalized ratio [INR] target 2.5; INR range 2.0 to 3.0) .

Test

1

In women with pathological stage III tumours bone scanning liver ultrasonography and chest radiography are recommended postoperatively as part of baseline staging.

Prescribe

1

If docetaxel and capecitabine are used in combination the recommended starting dose for most patients is 950 mg/m2 twice daily of capecitabine (75% of full dose) on days 1 to 14 plus docetaxel 75 mg/m2 intravenously on day 1 of a 21-day cycle.

Conclude

0.68

The review of raw data and the use of manual scoring for interpreting data from PM devices are recommended.

Monitor

0.65

The review of raw data and the use of manual scoring for interpreting data from PM devices are recommended.

Test

0.35

Although published studies have evaluated yearly screening in conjunction with mammography clinical breast examination and in some cases ultrasonography the appropriate screening interval for MRIB is not yet determined.

Prescribe

0.55

Narcotic use must be carefully titrated and supervised.

Prescribe

0.97

GH treatment is indicated in children with documented GHD for correction of hypoglycemia and for induction of normal statural growth.

Perform Therapeutic Procedure

1

In patients with limited-stage small cell lung cancer the addition of thoracic radiotherapy to standard combination chemotherapy improves both local control and overall survival and should be incorporated into a comprehensive treatment plan of combined modality therapy for limited-stage small cell lung cancer.

Test

1

If CIN is identified at the margins of a diagnostic excisional procedure or in a postprocedure endocervical sampling it is preferred that the 4- to 6-month follow-up visit include a colposcopic examination and an endocervical sampling .

Prepare

1

In choosing the components for a clinically relevant vaccine the physician should be familiar with local and regional aerobiology and indoor and outdoor allergens paying special attention to potential allergens in the patient's own environment.

Test

0.82

Stage Ib1 should be distinguished from stage Ib2 carcinoma of the cervix because the distinction predicts nodal involvement and overall survival and may therefore affect treatment and outcome.

Test

0.67

Stage Ib1 should be distinguished from stage Ib2 carcinoma of the cervix because the distinction predicts nodal involvement and overall survival and may therefore affect treatment and outcome.

Prescribe

0.27

All adults and adolescents with chronic kidney disease (CKD) should be evaluated for dyslipidemias.

Prescribe

1

Combination oxaliplatin short-term infusional 5-fluorouracil (5FU) and folinic acid (FA) (FOLFOX) is an important component of therapy and oxaliplatin should be made available for the treatment of advanced colorectal cancer.

Prescribe

1

This guidance applies to the use of the aromatase inhibitors anastrozole exemestane and letrozole within the marketing authorisations for each drug at the time of this appraisal for the treatment of early oestrogen-receptor-positive breast cancer; that is:Anastrozole for primary adjuvant therapyExemestane for adjuvant therapy following 2?3 years of adjuvant tamoxifen therapyLetrozole for primary adjuvant therapy and extended adjuvant therapy following standard tamoxifen therapy.

Perform Therapeutic Procedure

1

Laparoscopic (including laparoscopically assisted) resection is recommended as an alternative to open resection for individuals with colorectal cancer in whom both laparoscopic and open surgery are considered suitable.

Prescribe

1

Antipsychotics should be used to treat agitation or psychosis in patients with dementia where environmental manipulation fails (Standard). Atypical agents may be better tolerated compared with traditional agents .

Prescribe

1

There is insufficient evidence to support a role for IV bisphosphonates as an adjunctive therapy to radiation therapy in women with pain caused by metastatic bone disease when systemic chemotherapy and/or hormonal therapy is not being used. The role of bisphosphonates vis-a-vis radiation therapy as the sole therapy in this setting has not been determined. In women already being treated with local radiotherapy who have persistent or recurrent pain bisphosphonates are an attractive but little-studied salvage therapy.

Prescribe

1

Consider aspirin therapy (75 to 162 mg) in intermediate-risk women as long as blood pressure is controlled and benefit is likely to outweigh risk of gastrointestinal side effects.

Analgesia/symptomatic treatment:Recognize that a number of morbidities commonly seen in homeless patients including untreated dental problems hepatitis and traumatic injuries can result in chronic pain. It is important to remember that some drugs such as methadone and other narcotics can increase or decrease the effects of pain medications. Work with the patient to understand the underlying cause of pain. Prescribe appropriate pain medication and document why you prescribed it. To avoid overmedicating or contributing to drug-seeking behavior specify the plan of care in a written contract with the patient designating a single provider for pain prescription refills. Consider providing a cough suppressant or analgesia for a child??s acute ear infection if not detrimental to allow the child to sleep. A crying child will disrupt other shelter residents which could place the family at risk for eviction.

Perform Therapeutic Procedure

0.97

Women with uncomplicated (extended or flexed leg) breech presentation at term should be offered a caesarean after full discussion of the risks and benefits.

Conclude

0.64

Women with uncomplicated (extended or flexed leg) breech presentation at term should be offered a caesarean after full discussion of the risks and benefits.

Prescribe

0.36

Glucose-6-phosphate dehydrogenase deficiency predisposes to haematological side effects and should be excluded in predisposed races. The side-effect profile of dapsone and sulphonamides is potentially hazardous in the elderly. These treatments should be considered only if other treatments are ineffective or contraindicated .

Perform Therapeutic Procedure

0.97

Women with one previous cesarean delivery with a low transverse incision are candidates for and should be offered a trial of labor (TOL).

Monitor

0.82

Confirm that the infant has a scheduled appointment with a primary care provider or health worker within five to seven days after birth.Schedule additional visits as needed until a consistent weight gain pattern has been established (III).Identify breastfeeding support resources within the community such as:International Board Certified Lactation Consultants (IBCLCs)Community health workers and home visitors trained to provide breastfeeding supportBreastfeeding clinic staffHealth department staff

Prescribe

1

Oligo- and amenorrhoeic women with PCOS may develop endometrial hyperplasia and later carcinoma. It is good practice to recommend treatment with progestogens to induce a withdrawal bleed at least every three to four months.

Perform Therapeutic Procedure

1

Decontamination of dermal exposures should include routine cleansing with mild soap and water. Removal of contact lenses and immediate irrigation with room temperature tap water is recommended for ocular exposures. All patients with symptoms of eye injury should be referred for an ophthalmologic exam .

Prescribe

1

Testosterone transdermal patches and topical gels or creams may be preferred over oral products based on their avoidance of first-pass hepatic effects documented with oral formulations.However only oral and intramuscular (IM) testosterone products for women are currently government-approved.

Educate/Counsel

1

To enable patients to choose between open and laparoscopic surgery (either by the transabdominal preperitoneal [TAPP] or by the totally extraperitoneal [TEP] procedure) they should be fully informed of all of the risks.

Prepare

0.46

To enable patients to choose between open and laparoscopic surgery (either by the transabdominal preperitoneal [TAPP] or by the totally extraperitoneal [TEP] procedure) they should be fully informed of all of the risks.

Perform Therapeutic Procedure

0.54

Any athlete who loses a significant amount of fluid during sports participation should weigh in before and after practices games meets and competitions. Each pound of weight loss should be replaced with 1 pint of fluid containing carbohydrates and electrolytes before the next practice or competition. Fluids should be available and the drinking of such should be encouraged at all practices and competitions.

Refer/Consult

0.88

Consider referral to a program that provides guidance on nutrition physical activity and psychosocial concerns.

Refer/Consult

0.95

Clinicians should refer patients who require treatment with multiple psychotropic medications and/or are using illicit substances for psychiatric consultation becauseof the risk of drug-drug interactions and toxicity.

Monitor

0.21

Clinicians should refer patients who require treatment with multiple psychotropic medications and/or are using illicit substances for psychiatric consultation becauseof the risk of drug-drug interactions and toxicity.

Educate/Counsel

0.64

Asthma should be considered well controlled if (1) asthma symptoms are twice a week or less; (2) rescue bronchodilator medication is used twice a week or less; (3) there is no nocturnal or early morning awaking; (4) there are no limitations of work school or exercise; (5) the patient and physician consider their asthma well controlled; and (6) the patient's peak expiratory flow (PEF) or forced expiratory volume in one second (FEV1) is normal or his or her personal best.

Prescribe

1

The first line of treatment in primary open angle glaucoma (POAG) is medical therapy and the choice of the drug depends on the target IOP the safety profile of the drug patient acceptance and cost.

Test

1

Ultrasonography and magnetic resonance imaging (MRI) are not associated with known adverse fetal effects. However until more information is available magnetic resonance imaging is not recommended for use in the first trimester.

Prescribe

1

For patients receiving neuromuscular blocking agents and corticosteroids every effort should be made to discontinue neuromuscular blocking agents as soon as possible.

Educate/Counsel

0.84

Dexamethasone should not be first-line therapy for obstetric cholestasis nor should it be used outside of a randomised controlled trial (RCT) without a thorough consultation with the woman.

Educate/Counsel

1

Individuals at high risk for developing diabetes need to become aware of the benefits of modest weight loss and participating in regular physical activity.

Test

1

People for whom liver biopsy poses a substantial risk (such as those with haemophilia or those who have experienced an adverse event after undergoing a previous liver biopsy) and people with symptoms of extra-hepatic HCV infection sufficient to impair quality of life may be treated on clinical grounds without prior histological classification.

Monitor

0.51

People for whom liver biopsy poses a substantial risk (such as those with haemophilia or those who have experienced an adverse event after undergoing a previous liver biopsy) and people with symptoms of extra-hepatic HCV infection sufficient to impair quality of life may be treated on clinical grounds without prior histological classification.

Educate/Counsel

0.43

The recommendations on choice of treatment and the importance of regular monitoring of effectiveness and tolerability are the same for specific groups such as children with learning disabilities as for the general population of children with epilepsy.

Prescribe

1

In most patients with a diagnosis of acute bronchitis beta2-agonist bronchodilators should not be routinely used to alleviate cough.In select adult patients with a diagnosis of acute bronchitis and wheezing accompanying the cough treatment with beta2-agonist bronchodilators may be useful.

Conclude

0.9

In patients with cough and incomplete or irreversible airflow limitation direct or indirect signs of small airways disease seen on high resolution computed tomography (HRCT) scan or purulent secretions seen on bronchoscopy nonbronchiectatic suppurative airways disease (bronchiolitis) should be suspected as the primary cause.

Perform Therapeutic Procedure

0.81

For patients with more advanced NSCLC (stages III and IV) external beam radiation and/or chemotherapy should usually be offered.

Test

0.99

In patients with chronic cough who live in areas with a high prevalence of TB this diagnosis should be considered but not to the exclusion of the more common etiologies.Sputum smears and cultures for acid fast bacilli and a chest radiograph should be obtained whenever possible.

Conclude

0.89

HIV-infected patients with CD4+ lymphocyte counts of <200 cells/microL or those patients with counts of >200 cells/microL with unexplained fever weight loss or thrush who have unexplained cough should be suspected of having Pneumocystis pneumonia tuberculosis and other opportunistic infections and should be evaluated accordingly.

Prescribe

0.99

In children with cough cough suppressants and other over the counter (OTC) cough medicines should not be used as patients especially young children may experience significant morbidity and mortality.

Educate/Counsel

1

Pediatricians can actively promote bone health and support the goal of achieving adequate calcium intakes by children and adolescents by promoting the recommended adequate intakes of the Food and Nutrition Board of the National Academy of Sciences.The prevention of future osteoporosis and the possibility of a decreased risk of fractures in childhood and adolescence should be discussed with patients and families as potential benefits for achieving these goals.

When the patient's pain is ongoing or severe clinicians should rate and document the patient's pain function and response to medication at each visit.

Prescribe

1

Children 7 through 9 years of age who never received any pediatric DTP/DTaP/DT or Td dose generally should receive 3 doses of Td: dose 2 is administered 4 weeks or more after dose 1 and dose 3 is administered 6 to 12 months or longer after dose 2. A 10-year-old child could receive Boostrix for 1 of these doses. A single dose of Tdap is recommended for adolescents 11 to 18 years of age who have completed a 3-dose Td series if the series did not include Boostrix during the 10th year; an interval of at least 5 years between the most recent Td dose and Tdap is suggested . Children 7 to 10 years of age who received other incomplete immunization schedules against tetanus diphtheria and pertussis should be immunized against tetanus and diphtheria according to catch-up recommendations (AAP 2003) using an all-Td schedule (except children in their 10th year who could receive a single dose of Boostrix substituted for 1 dose of Td).Children with no history or an incomplete history of pediatric DTP/DTaP/DT or Td immunization could have received doses.Health care professionals can obtain serologic testing for antibodies against tetanus and diphtheria. toxoids in these children. If tetanus and diphtheria toxoid antibody concentrations are each protective at >0.1 IU/mL then the child can be presumed to have been immunized against tetanus diphtheria and possibly pertussis and Td immunization may be deferred until the child is 11 to 12 years of age when Tdap vaccine should be given.

Monitor

0.28

Children 7 through 9 years of age who never received any pediatric DTP/DTaP/DT or Td dose generally should receive 3 doses of Td: dose 2 is administered 4 weeks or more after dose 1 and dose 3 is administered 6 to 12 months or longer after dose 2. A 10-year-old child could receive Boostrix for 1 of these doses. A single dose of Tdap is recommended for adolescents 11 to 18 years of age who have completed a 3-dose Td series if the series did not include Boostrix during the 10th year; an interval of at least 5 years between the most recent Td dose and Tdap is suggested . Children 7 to 10 years of age who received other incomplete immunization schedules against tetanus diphtheria and pertussis should be immunized against tetanus and diphtheria according to catch-up recommendations (AAP 2003) using an all-Td schedule (except children in their 10th year who could receive a single dose of Boostrix substituted for 1 dose of Td).Children with no history or an incomplete history of pediatric DTP/DTaP/DT or Td immunization could have received doses.Health care professionals can obtain serologic testing for antibodies against tetanus and diphtheria. toxoids in these children. If tetanus and diphtheria toxoid antibody concentrations are each protective at >0.1 IU/mL then the child can be presumed to have been immunized against tetanus diphtheria and possibly pertussis and Td immunization may be deferred until the child is 11 to 12 years of age when Tdap vaccine should be given.

Test

0.26

Children 7 through 9 years of age who never received any pediatric DTP/DTaP/DT or Td dose generally should receive 3 doses of Td: dose 2 is administered 4 weeks or more after dose 1 and dose 3 is administered 6 to 12 months or longer after dose 2. A 10-year-old child could receive Boostrix for 1 of these doses. A single dose of Tdap is recommended for adolescents 11 to 18 years of age who have completed a 3-dose Td series if the series did not include Boostrix during the 10th year; an interval of at least 5 years between the most recent Td dose and Tdap is suggested . Children 7 to 10 years of age who received other incomplete immunization schedules against tetanus diphtheria and pertussis should be immunized against tetanus and diphtheria according to catch-up recommendations (AAP 2003) using an all-Td schedule (except children in their 10th year who could receive a single dose of Boostrix substituted for 1 dose of Td).Children with no history or an incomplete history of pediatric DTP/DTaP/DT or Td immunization could have received doses.Health care professionals can obtain serologic testing for antibodies against tetanus and diphtheria. toxoids in these children. If tetanus and diphtheria toxoid antibody concentrations are each protective at >0.1 IU/mL then the child can be presumed to have been immunized against tetanus diphtheria and possibly pertussis and Td immunization may be deferred until the child is 11 to 12 years of age when Tdap vaccine should be given.

Refer/Consult

0.32

If blood pressure measurements are persistently elevated with a systolic blood pressure greater than 140 mm Hg or diastolic blood pressure greater than 90 mm Hg the patient should be referred for follow-up of possible hypertension and blood pressure management.

Prepare

0.24

If blood pressure measurements are persistently elevated with a systolic blood pressure greater than 140 mm Hg or diastolic blood pressure greater than 90 mm Hg the patient should be referred for follow-up of possible hypertension and blood pressure management.

Educate/Counsel

0.28

If blood pressure measurements are persistently elevated with a systolic blood pressure greater than 140 mm Hg or diastolic blood pressure greater than 90 mm Hg the patient should be referred for follow-up of possible hypertension and blood pressure management.

Prescribe

0.24

Prescription or provision of emergency contraception in advance of need can increase availability and use.

Refer/Consult

0.89

Drug treatment should only be initiated by an appropriately qualified healthcare professional with expertise in ADHD and should be based on a comprehensive assessment and diagnosis. Continued prescribing and monitoring of drug therapy may be performed by general practitioners under shared care arrangements.

Prescribe

1

Olanzapine and valproate semisodium within their licensed indications are recommended as options for control of the acute symptoms associated with the manic phase of bipolar I disorder.

Perform Therapeutic Procedure

1

Hotodynamic therapy (PDT) is recommended for the treatment of wet age-related macular degeneration for individuals who have a confirmed diagnosis of classic with no occult subfoveal choroidal neovascularisation (CNV) (that is whose lesions are composed of classic CNV with no evidence of an occult component) and best-corrected visual acuity 6/60 or better. PDT should be carried out only by retinal specialists with expertise in the use of this technology.

Monitor

0.97

The effectiveness of glitazone combination therapy should be monitored against treatment targets for glycaemic control (usually in terms of haemoglobin A1c [HbA1c] level) and for other cardiovascular risk factors including lipid profile. The target HbA1c level should be set between 6.5% and 7.5% depending on other risk factors.

Prescribe

1

Capecitabine monotherapy is recommended as an option for people with locally advanced or metastatic breast cancer who have not previously received capecitabine in combination therapy and for whom anthracycline and taxane-containing regimens have failed or further anthracycline therapy is contraindicated.

Educate/Counsel

0.96

In all situations where informed discussion and consent is not possible advance directives should be taken fully into account and the individual's advocate and/or carer should be consulted.

Prescribe

1

It is recommended that a GP IIb/IIIa inhibitor is considered as an adjunct to PCI for all patients with diabetes undergoing elective PCI and for those patients undergoing complex procedures (for example multi-vessel PCI insertion of multiple stents vein graft PCI or PCI for bifurcation lesions); currently only abciximab is licensed as an adjunct to PCI. In procedurally uncomplicated elective PCI where the risk of adverse sequelae is low use of a GP IIb/IIIa inhibitor is not recommended unless unexpected immediate complications occur.

Prepare

0.97

Adhere to a checklist protocol for anesthesia machines and equipment to assure that the desired anesthetic drugs and doses will be delivered.

Perform Therapeutic Procedure

0.87

Patients undergoing the following procedures are at higher risk for postoperative pulmonary complications and should be evaluated for other concomitant risk factors and receive pre- and postoperative interventions to reduce pulmonary complications: prolonged surgery (>3 hours) abdominal surgery thoracic surgery neurosurgery head and neck surgery vascular surgery aortic aneurysm repair emergency surgery and general anesthesia.

Educate/Counsel

0.99

Educate nurses families policy-makers and the public to respond to expected or unexpected life events within the family.

Prepare

0.91

Nurses embrace the following values and beliefs: respect; human dignity; clients are experts for their own lives; clients as leaders; clients' goals coordinate care of the healthcare team; continuity and consistency of care and caregiver; timeliness; responsiveness and universal access to care. These values and beliefs must be incorporated into and demonstrated throughout every aspect of client care and services.

Prescribe

1

Erlotinib at a dose of 150 mg/day is recommended as third-line therapy for patients with advanced recurrent or progressive non-small cell lung cancer who maintain a good performance status following previous platinum-based and docetaxel (or pemetrexed) chemotherapy. Erlotinib is also an option for second-line therapy particularly in patients who are not candidates for chemotherapy or for those with progression after first-line docetaxel-platinum chemotherapy.

Prescribe

0.99

Antibiotic therapy can be deferred for many asymptomatic patients and for most cases of OME .

Prepare

0.73

Antibiotic therapy can be deferred for many asymptomatic patients and for most cases of OME .

Several models for the implementation of AED programmes outside the EMS have been described: we have identified three main strategies that have different and to some extent opposite characteristics.It is recommended that once the priorities of implementation of an AED programme within the EMS have been achieved a careful analysis is conducted in order to identify the community model that is most suitable for the specific environment. A cost-effectiveness analysis is an essential part of the implementation strategy. Every hospital should analyse whether the goal of early defibrillation is achieved and AED implementation can be an important element in improving the in-hospital chain of survival. Home programmes are still in a preliminary phase of implementation: families with a genetic predisposition to sudden cardiac death and families with high risk individual(s) who are not scheduled for or cannot receive an implantable cardioverter defibrillator (ICD) represent the primary target for pilot projects on home defibrillation.

Test

1

Assess the size and the degree of intravesical prostatic protrusion (IPP) with transabdominal ultrasound scan. This information helps to predict the natural history of the disease.

Educate/Counsel

0.99

Consent should be obtained and documented for every procedure. In addition to the risks associated with all endoscopic procedures the consent should address the relevant and substantial complications pertaining to each specific EUS procedure.

Prescribe

1

It is recommended that cefuroxime cefpodoxime and cefdinir be second-line therapy for pediatric ABS .

Prescribe

0.95

If survival is the main outcome of interest for a patient it is reasonable to offer chemotherapy to medically suitable patients as an option for this condition with a full discussion of the benefits limitations and toxicities.

Inquire

1

Prompt investigation of the scene at which the infant was found lifeless or unresponsive and careful interviews of household members by knowledgeable individuals with the legal authority and mandate to conduct such investigations.

Test

0.99

Lateral flexion and extension radiography is recommended as an adjunct to determine the presence of lumbar fusion postoperatively. The lack of motion between vertebrae in the absence of rigid instrumentation is highly suggestive of successful fusion.

Test

1

Additional Laboratory Tests. It is recommended that patients with no apparent etiology of HF or no specific clinical features suggesting unusual etiologies undergo additional directed blood and laboratory studies to determine the cause of HF.

Examine

1

The foot examination can be accomplished in a primary care setting and should include the use of a monofilament tuning fork palpation and a visual examination.

Prepare

1

Nurses working with individuals with asthma must have the appropriate knowledge and skills to:Identify the level of asthma control Provide basic asthma education Conduct appropriate referrals to physician and community resources

Prescribe

0.99

Glutamine may be beneficial in select patients. To identify which patients may benefit each constituent RCT should be reviewed and clinical judgement should be exercised.

Prescribe

1

One randomized phase II study and six phase II studies have shown encouraging response rates when thalidomide is combined with temozolomide. However dosing schedules of temozolomide in those studies differed from conventional prescribed doses and schedules. It is not clear whether the improved response rates were due to the small number of patients in the studies the different dose schedules of temozolomide or the addition of thalidomide. Further phase III studies are required to confirm whether there is a benefit associated with the combination of temozolomide and thalidomide. Therefore it is not recommended that thalidomide be combined with temozolomide at this time.

Perform Therapeutic Procedure

0.98

Patients who have a single lesion can be offered surgical resection if they are non-cirrhotic or have cirrhosis but still have well preserved liver function normal bilirubin and hepatic vein pressure gradient <10 mmHg .

An EDH less than 30 cm3 and with less than a 15-mm thickness and with less than a 5-mm midline shift (MLS) in patients with a GCS score greater than 8 without focal deficit can be managed nonoperatively with serial computed tomographic (CT) scanning and close neurological observation in a neurosurgical center

Perform Therapeutic Procedure

0.89

Patients with parenchymal mass lesions who do not show evidence for neurological compromise have controlled intracranial pressure (ICP) and no significant signs of mass effect on CT scan may be managed nonoperatively with intensive monitoring and serial imaging.

Prescribe

1

Alkylating-agent based therapy is appropriate for the initial and subsequent treatment of Waldenstrom's Macroglobulinaemia.

Conclude

1

Where myeloma and AL amyloidosis co-exist choice of treatment for myeloma should take into account the extent of organ involvement with amyloid and the potential toxicities of individual treatments .

Prepare

1

Institutional policies should be developed for provision of patient- and family-centered care through environmental design practice and staffing in collaboration with patients and their families.

Test

0.22

Institutional policies should be developed for provision of patient- and family-centered care through environmental design practice and staffing in collaboration with patients and their families.

Educate/Counsel

0.75

Patients currently treated in hospital who are potentially suitable for home haemodialysis on clinical grounds but who have not previously been offered a choice should be reassessed and informed about their dialysis options.

Routine Tdap Vaccination:Recommendations for Use: Adults aged 19 to 64 years should receive a single dose of Tdap to replace a single dose of tetanus and diphtheria toxoids vaccine (Td) for active booster vaccination against tetanus diphtheria and pertussis if they received their last dose of Td >10 years earlier. Replacing 1 dose of Td with Tdap will reduce the morbidity associated with pertussis in adults and might reduce the risk for transmitting pertussis to persons at increased risk for pertussis and its complications.

Perform Therapeutic Procedure

0.87

Hypnotherapy:Most widely studied and used psychological therapy for diarrhea and pain-predominant symptoms. Improvements have been seen in all symptom measures quality of life and overall well-being. Of the controlled randomized studies in the last five years all studies noted improvement with gut-directed hypnotherapy versus placebo in reducing diarrhea-predominant and pain-predominant symptoms. Twenty years after hypnotherapy was introduced as an effective treatment for IBS the mechanisms behind the results are still unclear.

Prescribe

0.84

The stage of ovarian cancer is an important prognostic factor that influences survival and the choice of therapy. The quality of the surgical staging is a key determinant of treatment recommendations.

Educate/Counsel

1

Epidemiology and Prevention:Clinicians should encourage all patients with HCV and all patients with HIV who are sexually active to use condoms.

Patient Education:Assess Patient Needs.An important first step in optimizing patient education is to adequately assess each patient's needs. Take into account patients' level of knowledge about their headaches. Also be aware of their attitudes beliefs and cultural background and how these elements might affect the treatment process. Be sensitive to environmental and social factors which can also play a role in determining patients' receptivity to treatment.

Educate/Counsel

0.59

Carers: Older people who are carers of people with intellectual or other disabilities should be assessed for health and support needs.

In patients who fail to respond to therapy with methylprednisolone in the dose range used in the randomized placebo-controlled trials treatment with higher doses (up to 2 g daily for 5 days) should be considered.

Educate/Counsel

0.87

Nurses will educate clients about self/home blood pressure monitoring techniques and appropriate equipment to assist in potential diagnosis and the monitoring of hypertension.

Prescribe

0.99

Long-term follow up in a specialized clinic is unnecessary for uncomplicated disease that is well controlled clinically using small amounts of a topical corticosteroid and follow up should be reserved for patients with complicated LS that is unresponsive to treatment and those patients who have persistent disease with history of a previous SCC.

Perform Therapeutic Procedure

0.23

Long-term follow up in a specialized clinic is unnecessary for uncomplicated disease that is well controlled clinically using small amounts of a topical corticosteroid and follow up should be reserved for patients with complicated LS that is unresponsive to treatment and those patients who have persistent disease with history of a previous SCC.

Prescribe

0.76

Disseminated Infection (Extrapulmonary):Nonmeningeal:Amphotericin B is recommended for alternative therapy especially if lesions are appearing to worsen rapidly and are in particularly critical locations such as the vertebral column.

Test

0.98

Testing may also be performed to reassure the patient parent and physician of the absence of organic disease particularly if the pain significantly diminishes the quality of life of the patient.

Prescribe

1

Principles of Treatment Selection:Certain types of psychotherapy (as well as other psychosocial modalities) and certain psychotropic medications are effective in the treatment of borderline personality disorder.

Perform Therapeutic Procedure

1

Women with early stage (stages I and II) breast cancer who have undergone breast conservation surgery should be offered postoperative breast irradiation.

Prepare

0.76

Understand measures of morbidity/mortality and study designs.

Educate/Counsel

1

Because much of the risk of developing type 2 diabetes is attributable to obesity maintenance of a healthy body weight is strongly recommended as a means of preventing this disease. The relationship between glycemic index and glycemic load and the development of type 2 diabetes remains unclear at this time.

Monitor

0.27

Because much of the risk of developing type 2 diabetes is attributable to obesity maintenance of a healthy body weight is strongly recommended as a means of preventing this disease. The relationship between glycemic index and glycemic load and the development of type 2 diabetes remains unclear at this time.

Test

0.72

Although an increased cancer risk has not been established in patients with Barrett's esophagus and low-grade dysplasia endoscopy at 6 months and yearly thereafter should be considered .

Educate/Counsel

1

Monitoring of Nutrition Support in Hospital and the Community :If long-term nutrition support is needed patients and carers should be trained to recognise and respond to adverse changes in both their well-being and in the management of their nutritional delivery system.

Prescribe

1

Key Recommendations by Diagnosis:Candidemia and Acute Hematogenously Disseminated Candidiasis:For clinically stable patients who have not recently received azole therapy fluconazole (>6 mg/kg per day; i.e. >400 mg/day for a 70-kg patient) is another appropriate choice.

Monitor

0.95

Guideline 5: Treatment of Duodenal Adenomas Depends on Adenoma Size and the Presence of Severe Dysplasia. Small Tubular Adenomas With Mild Dysplasia Can Be Kept Under Surveillance But Adenomas With Severe Dysplasia Must Be Removed.

Prepare

1

The panel recommends the following:Formation of a federation of celiac disease societies celiac disease interest groups individuals with celiac disease and their families physicians dietitians and other health care providers for the advancement of education research and advocacy for individuals with celiac disease.

Monitor

0.53

The panel recommends the following:Formation of a federation of celiac disease societies celiac disease interest groups individuals with celiac disease and their families physicians dietitians and other health care providers for the advancement of education research and advocacy for individuals with celiac disease.

Test

0.47

Interpretation of Serum Human Chorionic Gonadotropin (hCG) Levels:Arrange follow-up for patients with a nondiagnostic transvaginal ultrasound and a serum hCG level above 2 000 mIU/mL because they have an increased likelihood of ectopic pregnancy.

Fire hoses are sometimes found in hallways and stairwells of older facilities. Water from hoses is not sterile. The water can also create an electric shock hazard. In addition the water stream itself can deliver sufficient force to cause injury or mechanical damage and can make the hose difficult to hold onto. The guideline developers do not recommend the uses of fire hoses to extinguish surgical fires.

Test

1

Paracentesis:Abdominal paracentesis may be helpful to confirm the presence of intestinal gangrene in infants with NEC . Indications for paracentesis are absence of pneumoperitoneum and one of the following:Portal venous gas.Erythema of abdominal wall.Fixed tender abdominal mass.Persistently dilated intestinal segment.Clinical deterioration

Prescribe

1

Regardless of combination trastuzumab should be initiated at 4mg/kg and continued at 2mg/kg weekly until disease progression or unacceptable toxicity.

Prescribe

0.99

Zanamivir and oseltamivir are not recommended for the treatment of influenza in children or adults unless they are considered to be at risk.

Prevent

0.33

Zanamivir and oseltamivir are not recommended for the treatment of influenza in children or adults unless they are considered to be at risk.

Results and Recommendations:Which features of the neurologic examination of the comatose patient are predictive of outcome?The prognosis is invariably poor in comatose patients with absent pupillary or corneal reflexes or absent or extensor motor responses 3 days after cardiac arrest .

Test

1

Radiologic Assessment:It is recommended in children age 6 to 18 years and weight >18 kg [>40 lbs] (for whom surgery is being considered that an AP pelvis x-ray also be obtained to evaluate the status of growth plates near the proximal femur as well as to aid in ruling out the presence of femoral neck fracture.

Monitor

0.99

Recommendation:When providing physical activity advice primary care practitioners should take into account the individual's needs preferences and circumstances. They should agree goals with them. They should also provide written information about the benefits of activity and the local opportunities to be active.They should follow them up at appropriate intervals over a 3- to 6-month period.

Perform Therapeutic Procedure

1

In appropriate patients with gallbladder cancer or cholangiocarcinoma surgical resection offers the best chance for survival and should be the first treatment of choice.

Perform Therapeutic Procedure

1

Recommendations:Penicillin Allergy Skin Testing :If the full battery of skin-test reagents is available including the major and minor determinants patients who report a history of penicillin reaction and are skin-test negative can receive conventional penicillin therapy. Skin-test-positive patients should be desensitized.

Prescribe

0.99

Scabies:Recommended Regimen:Permethrin cream (5%) applied to all areas of the body from the neck down and washed off after 8-14 hours.ORIvermectin 200 micrograms/kg orally repeated in 2 weeks.

Monitor

0.86

Follow-up:For patients at lower risk of recurrence (stages I and Ia) or those with co-morbidities impairing future surgery only visits yearly or when symptoms occur are recommended.

Prescribe

1

Medical Recommendations:Care should focus on smoking hypertension lipids and glycemic control:Treatment of hypertension using up to 3 or 4 anti-hypertensive medications to achieve adult target of <130 systolic and <80 diastolic .Prescription of angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) in patients with hypertension or albuminuria.Statin therapy for primary prevention against macrovascular complications in patients with diabetes who are >age 40 or who have a low-density lipoprotein cholesterol (LDL-C) >100 mg/dL. Management of cardiovascular risk factorsAssurance of appropriate immunization status (tetanus diphtheria pertussis influenza pneumococcal vaccine) .Anti-platelet therapy : low dose aspirin daily for primary prevention in those at increased cardiovascular risk with type 1 and type 2 diabetes unless contraindicated.

Test

0.91

HIV Screening for Pregnant Women and Their Infants:Screening should occur after a woman is notified that HIV screening is recommended for all pregnant patients and that she will receive an HIV test as part of the routine panel of prenatal tests unless she declines (opt-out screening).

Conclude

1

Patient Management Recommendations. Assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (AMI) and presenting within 12 hours of symptom onset if ECG reveals:1.ST elevations greater than or equal to 0.1 millivolts (mV) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mV (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of ST-segment elevation (e.g. early repolarization pericarditis left ventricular hypertrophy [LVH] incomplete bundle branch block [BBB]).2.Any type of BBB (right left and atypical ? new or old) thought to be obscuring ST-segment analysis in patients with clinical presentation strongly suggestive of AMI.

Monitor

0.72

Patient Management Recommendations. Assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (AMI) and presenting within 12 hours of symptom onset if ECG reveals:1.ST elevations greater than or equal to 0.1 millivolts (mV) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mV (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of ST-segment elevation (e.g. early repolarization pericarditis left ventricular hypertrophy [LVH] incomplete bundle branch block [BBB]).2.Any type of BBB (right left and atypical ? new or old) thought to be obscuring ST-segment analysis in patients with clinical presentation strongly suggestive of AMI.

Educate/Counsel

0.28

Pelvic Examination:Recommendation:Regular gynecologic follow-up is recommended for all women. Patients who receive tamoxifen therapy are at increased risk for developing endometrial cancer and should be advised to report any vaginal bleeding to their physicians. Longer follow-up intervals may be appropriate for women who have had a total hysterectomy and oophorectomy.

Test

0.67

Pelvic Examination:Recommendation:Regular gynecologic follow-up is recommended for all women. Patients who receive tamoxifen therapy are at increased risk for developing endometrial cancer and should be advised to report any vaginal bleeding to their physicians. Longer follow-up intervals may be appropriate for women who have had a total hysterectomy and oophorectomy.

Prescribe

0.32

Follow-Up:Failure to improve within 3 days of the initiation of treatment requires reevaluation of both the diagnosis and therapy. Swelling and tenderness that persist after completion of antimicrobial therapy should be evaluated comprehensively.

Prescribe

1

The current state of the evidence does not permit a recommendation for an optimal cisplatin-based combination chemotherapy regimen. However the largest neoadjuvant trials have used standard methotrexate-vinblastine-doxorubicin-cisplatin (MVAC) or cisplatin-methotrexate-vinblastine (CMV) for three cycles and it is the opinion of the Genitourinary Cancer Disease Site Group that these regimens are reasonable treatment options.

Prescribe

1

Management:General Advice:Ideally treatment should be effective (microbiological cure rate >95%) easy to take (not more than twice daily) with a low side effect profile and cause minimal interference with daily lifestyle .

Test

0.79

Carnitine:Similar results have been noted in the treatment of cardiac and peripheral vascular ischemic disease .

Prepare

1

The Task Force recommends further study of physiologic targets of androgen action such as:Sexual dysfunctionCognitionMoodBoneCardiovascular functionBody compositionMuscle strength and function

Prepare

0.24

The Task Force recommends further study of physiologic targets of androgen action such as:Sexual dysfunctionCognitionMoodBoneCardiovascular functionBody compositionMuscle strength and function

Educate/Counsel

0.34

Use of a combination of oral sucrose/glucose and other nonpharmacologic pain-reduction methods (nonnutritive sucking kangaroo care facilitated tuck swaddling developmental care) should be used for minor routine procedures.

Educate/Counsel

1

Genetic testing along with counseling is recommended for individuals with hereditary forms of CRC including familial adenomatous polyposis (FAP) and hereditary nonpolyposis colon cancer (HNPCC) .

Educate/Counsel

0.3

Genetic testing along with counseling is recommended for individuals with hereditary forms of CRC including familial adenomatous polyposis (FAP) and hereditary nonpolyposis colon cancer (HNPCC) .

Prescribe

0.67

Discussions should occur with the patient or legal agent about life expectancy and quality of life.

Test

0.92

Perform a comprehensive neurological examination according to International Standards for Neurological and Functional Classification between 3 and 7 days after injury.

Prepare

1

To be most effective condom availability programs should be developed through a collaborative community process and accompanied by comprehensive sequential sexuality education which is ideally part of a K-12 health education program with parental involvement counseling and positive peer support.

Test

0.21

To be most effective condom availability programs should be developed through a collaborative community process and accompanied by comprehensive sequential sexuality education which is ideally part of a K-12 health education program with parental involvement counseling and positive peer support.

Educate/Counsel

0.21

To be most effective condom availability programs should be developed through a collaborative community process and accompanied by comprehensive sequential sexuality education which is ideally part of a K-12 health education program with parental involvement counseling and positive peer support.

Perform Therapeutic Procedure

0.4

Certain APAP devices may be used during attended titration to identify by polysomnography a single pressure for use with standard continuous positive airway pressure (CPAP) for treatment of OSA.

Perform Therapeutic Procedure

0.99

The laryngeal mask airway and Combitube are alternatives to cricothyrostomy and may be selected when cricothyrostomy expertise is limited.

Prescribe

1

If the patient has been treated with one of these medications within the past 6 months (as would be the case if the initial treatment was unsuccessful) resistance to that agent should be suspected and a different agent should be chosen for treatment.

The control of risk factors such as diabetes mellitus and cigarette smoking should be initiated once the initial event has stabilised.

Test

1

Bone mineral density (BMD) should normally be measured by DXA scanning performed on two sites preferably anteroposterior spine and hip.

Monitor

0.34

Bone mineral density (BMD) should normally be measured by DXA scanning performed on two sites preferably anteroposterior spine and hip.

Test

0.63

Digital cervical examination should not be performed in patients with PROM who are not in labor and in whom immediate induction of labor is not planned.

Perform Therapeutic Procedure

0.9

Preoperative Care:Patients should be operated on as soon as possible (within 24 hours) during standard daytime working hours including weekends if their medical conditions allows.

Prescribe

1

Nutrient treatment or supplementation zinc or calcium supplementation plasma volume expansion maternal oxygen therapy antihypertensive therapy heparin and aspirin therapy have not been shown to be effective for prevention or treatment of IUGR.

Prescribe

1

Anticoagulants should be continued until discharge in patients with incomplete injuries for 8 weeks in patients with uncomplicated complete motor injury and for 12 weeks or until discharge from rehabilitation for those with complete motor injury and other risk factors (e.g. lower limb fractures a history of thrombosis cancer heart failure obesity or age over 70).

Test

1

Patients presenting to the emergency department with headache and abnormal findings in a neurologic examination (i.e. focal deficit altered mental status altered cognitive function) should undergo emergent* noncontrast head computed tomography (CT) scan.Patients presenting with acute sudden-onset headache should be considered for an emergent* head computed tomography scan.Human immunodeficiency virus (HIV)-positive patients with a new type of headache should be considered for an urgent* neuroimaging study.Patients who are older than 50 years presenting with new type of headache without abnormal findings in a neurologic examination should be considered for an urgent neuroimaging study.

Test

0.81

For older women assess blood pressure in both the standing and sitting or supine position.

Perform Therapeutic Procedure

0.41

For older women assess blood pressure in both the standing and sitting or supine position.

Prescribe

0.51

Pancreatitis PN should be used in patients with pancreatitis if SNS is indicated and EN is not tolerated.

Test

0.93

Assess for neurocognitive deficits and wandering patterns using the Algase Wandering Scale (AWS).

Prescribe

1

If endogenous erythropoietin levels are <500 mUnits/mL erythropoietin therapy (50-200 iu/kg/dose 3 times/week) should be administered to reduce the need for transfusion. Supplemental oral iron (3-6 mg/kg/day of elemental iron) and folate (1 mg/day) should be administered when erythropoietin is initiated.

Test

1

Photoscreening is an innovative tool that can facilitate vision screening in children especially in children who are difficult to screen (i.e. infants toddlers and children with developmental delays). Photoscreening systems are one option to increase the screening rate in preschool-aged children.

Prepare

1

Organize randomized controlled trials (RCTs) to extend treatment to special populations not represented in current clinical trials and to determine the applicability of accepted antiviral drug combinations to populations such as children and adolescents and patients with acute hepatitis. Effective approaches are needed for drug users receiving drug treatment alcohol abusers prisoners patients with stabilized depression those with co-infection with human immunodeficiency virus patients with decompensated cirrhosis and HCV infections in transplant recipients. Such efforts should lead to decreased morbidity and mortality from the disease as well as a decrease in the reservoir of disease.

Test

0.91

The U.S. Preventive Services Task Force recommends screening mammography with or without clinical breast examination every 1-2 years for women aged 40 and older.

Monitor

0.82

Blood ketone determinations that rely on the nitroprusside reaction should be used only as an adjunct to diagnose DKA and should not be used to monitor treatment of DKA.

Test

1

Neuroimaging Routine neuroimaging (magnetic resonance imaging [MRI]/computed tomography [CT]) is not recommended in children with first unprovoked seizures unless the history physical exam or neurologic and developmental assessment suggest focality or deterioration/delay in which case an MRI is the procedure of choice.

Pediatricians should be aware of the careful balance that needs to be in place to decrease the growing prevalence of eating disorders in children and adolescents.

Prepare

0.47

Pediatricians should be aware of the careful balance that needs to be in place to decrease the growing prevalence of eating disorders in children and adolescents.

Perform Therapeutic Procedure

0.28

If a patient has GFR <30 mL/min/1.73 m2 and it has been determined that s/he will receive hemodialysis veins suitable for placement of vascular access should be preserved .

Educate/Counsel

0.99

Prior to the death of the resident the Bereavement Leader should provide information about end-of-life care services and assistance in contacting these services.

Test

1

In the absence of an outcomes validated approach to nutrition assessment a combination of clinical (history and physical exam) and biochemical parameters should be used to assess the presence of malnutrition.

Prepare

0.83

Fluid and Electrolytes Water and electrolyte requirements should be adjusted in pediatric patients undergoing surgical procedures or who have on-going losses from stomas or other sites.

Test

1

General Approach to Diagnosis A patient with a solitary peripheral lesion that is even moderately suspicious for lung cancer who appears to have early-stage disease (i.e. negative findings on a chest computed tomography [CT] of the mediastinum) and is a surgical candidate should undergo excisional biopsy and subsequent lobectomy if a resectable lung cancer is confirmed.

Test

1

In patients who have extensive mediastinal infiltration with tumor (T4 involvement or involvement to the point of not being able to see discrete lymph nodes) the primary goal of an invasive procedure is to provide confirmation of the diagnosis. (The radiographic staging of mediastinal node involvement is compelling.) For these patients transthoracic needle aspiration (TTNA) and endoscopic ultrasound-guided needle aspiration (EUS-NA) are procedures of choice based on high sensitivity (approximately 90%) and low morbidity (outpatient procedure).

Perform Therapeutic Procedure

1

Patients with stage I NSCLC deemed medically unable to tolerate operative intervention or refusing surgical resection and having no medical contraindication to radiation therapy should receive this modality as definitive treatment.

Educate/Counsel

1

The USPSTF concludes that the evidence is insufficient to recommend for or against the use of counseling of any intensity and behavioral interventions to promote sustained weight loss in overweight adults.

Test

1

A complete survey that includes the head and neck chest abdomen and pelvis is recommended when PTLD is suspected.

Educate/Counsel

1

Patients who are able and willing should be informed and educated about risk assessment and resulting prevention strategies. This strategy where appropriate should include carers .

Prescribe

0.72

Monitor the patient's condition and response to treatment.

Test

0.7

Monitor the patient's condition and response to treatment.

Prepare

0.3

Head lice screening programs have not been proven to have a significant effect on the incidence of head lice in the school setting over time and are not cost-effective. Parent education programs may be helpful in the management of head lice in the school setting.

Infants and children requiring tube feedings for eating disorders should receive the minimum supplemental support necessary to maintain growth and development.

Prescribe

1

Combination platinum-based chemotherapy can be administered safely and with acceptable and manageable toxicity profiles in patients with good PS who have stage IV NSCLC.

Prescribe

1

Elderly patients with good performance status and with intact organ function should be treated with platinum-based chemotherapy.

Prescribe

0.9

Ongoing Care For patients with lung cancer in whom death or a significant change in clinical status occurs the primary care physician and all management team members should be advised. Likewise the primary care physician should notify the management team and all interested parties if a change in clinical status of the patient should occur at home.

Refer/Consult

1

For optimal functional results people with disabling arthritis should be referred for surgical care prior to the onset of joint contracture severe deformity and advanced muscular wasting and deconditioning rather than as a last resort.

Refer/Consult

0.99

A selective estrogen receptor modulator (SERM) has been approved by the FDA for the prevention and treatment of osteoporosis in menopausal women. A bone disease specialist should participate in the decision to choose a SERM in patients with GI diseases.

Monitor

1

Home cardiorespiratory monitoring may be warranted for premature infants who are at high risk of recurrent episodes of apnea bradycardia and hypoxemia after hospital discharge. The use of home cardiorespiratory monitoring in this population should be limited to approximately 43 weeks postmenstrual age or after the cessation of extreme episodes whichever comes last.

Monitor

1

Patients should be told of the risks of hepatocellular carcinoma (HCC) associated with chronic hepatitis B infection and offered the option of hepatocellular carcinoma surveillance. For patients who are agreeable to surveillance ultrasonography and serum alpha-fetoprotein should be done at regular intervals. Ultrasonography should be done at 6- and 12-monthly intervals for cirrhotic and non-cirrhotic patients respectively. Patients' blood should be sampled for alpha-fetoprotein every 3 to 6 months and 6 to 12 months for cirrhotic and non-cirrhotic patients respectively.

Monitor

1

HIV-infected patients should be screened for behaviors associated with HIV transmission by using a straightforward nonjudgmental approach. This should be done at the initial visit and subsequent routine visits or periodically as the clinician feels necessary but at a minimum of yearly. Any indication of risky behavior should prompt a more thorough assessment of HIV transmission risks.

Prescribe

1

Hormone replacement therapy should be considered for women undergoing prophylactic oophorectomy and patients should be counseled about the risks and benefits of hormone replacement therapy prior to undergoing surgery.

An underlying coagulopathy such as von Willebrand's disease should be considered in all patients (particularly adolescents) with abnormal uterine bleeding especially when bleeding is not otherwise easily explained or does not respond to medical therapy.

Prescribe

1

Patients without a history of thrombosis but who have an underlying thrombophilia and have a strong family history of thrombosis also are candidates for antepartum and postpartum prophylaxis. At the minimum postpartum prophylaxis should be offered.

Because there are no data on the use of raloxifene in women who have completed a 5-year course of tamoxifen therapy such women should have an individual assessment of their risk of osteoporosis and decisions about prevention or treatment should be made accordingly.

Prescribe

1

The optimal progestin duration and frequency of treatment to prevent endometrial cancer in women with PCOS is unknown.

Monitor

0.61

Expectant management of patients with preterm labor or preterm premature rupture of membranes and active HSV may be warranted.

Perform Therapeutic Procedure

1

Patients referred to an epilepsy surgery center for the reasons stated above who meet established criteria for an anteromesial temporal lobe resection and who accept the risks and benefits of this procedure as opposed to continuing pharmacotherapy should be offered surgical treatment.

Prepare

0.34

Patients referred to an epilepsy surgery center for the reasons stated above who meet established criteria for an anteromesial temporal lobe resection and who accept the risks and benefits of this procedure as opposed to continuing pharmacotherapy should be offered surgical treatment.

Educate/Counsel

0.66

Pediatricians should promote the active participation of all children in the management and direction of their own health care beginning at an early age and continuing into adult health care.

Advocate

1

Pediatricians and child health professionals should join with the national American Academy of Pediatrics (AAP) and AAP chapters in the following activities:Vigorously advocating for all children to receive comprehensive health care including childhood immunizations in a medical home ( The medical home 2002). Children most likely to experience barriers to comprehensive care in a medical home are children who are members of racial and ethnic minorities poor or uninsured children children living in inner-city or rural areas and children with chronic medical conditions.Collaborating with local public and private child health services to identify children without access to a medical home and assist in referring them to a medical home. The medical home should maintain the children's medical records including immunization records.Removing economic barriers to immunizations for parents and pediatricians to participate in the Vaccines for Children (VFC) Program or state vaccine programsReducing socioeconomic and racial disparities in immunization rates by working with all national medical groups and specialty societies that care for poor and underserved populationsAdvocating with state vaccine purchasing or Vaccines for Children programs and private third-party payers of vaccine for adequate vaccine reimbursement rates that cover all costs associated with the administration of vaccines including the vaccines product physician work practice administrative expense professional liability and all related supplies including safety needlesAdvocating with vaccine manufacturers and state and federal governments to maintain an adequate supply of all childhood vaccines at all timesEnsuring that the safest and most effective vaccines and combinations are available to childrenAdvocating with state and federal governments to ensure that timely access to all immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) the AAP and the American Academy of Family Physicians (AAFP) for all children remains a high public policy prioritySupporting ongoing education and quality improvement programs for pediatricians and other child health care professionals about important vaccine-related issues including the dissemination of peer-reviewed evidence for more effective immunization delivery.

Educate/Counsel

0.93

Help parents teachers coaches and others who influence youth to discuss health habits not body habitus as part of their efforts to control overweight and obesity.

Inquire

0.58

Complete a comprehensive history of presenting symptoms with particular attention to history of onset duration morphology of nail predisposing factors and prior treatments and outcomes.

Prescribe

0.94

Measurements of tissue (subcutaneous or muscle) oxygen and/or carbon dioxide levels may identify patients who require additional resuscitation and are at risk for multiple organ dysfunction syndrome and death.

Document

1

Each co-surgeon must adequately document his/her respective preoperative intraoperative and postoperative participation according to Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards.

There is insufficient evidence to recommend allogeneic transplantation as routine therapy for multiple myeloma. Patients who are potentially eligible for transplantation should be referred for transplant assessment early after diagnosis and should not be given extensive exposure to alkylating agents such as melphalan prior to the collection of stem cells. High-dose glucocorticoid-based regimens such as vincristine doxorubicin (Adriamycin) dexamethasone (VAD) are preferable for such patients.

Prescribe

0.9

Diuretic-sensitive patients should preferably be treated with sodium restriction and oral diuretics rather than with serial paracenteses .

Educate/Counsel

0.99

Is combined androgen blockade better than castration alone?Recommendation: A discussion should occur between the patient and his practitioner. The patient needs to appreciate that there is a small potential gain in overall survival (OS) with the addition of a nonsteroidal antiandrogen to medical or surgical castration and that increased side effects may occur as a result.

Refer/Consult

0.99

Children and adolescents with newly suspected and/or recurrent malignancy should be referred to a pediatric cancer center for prompt and accurate diagnosis and management.

Prescribe

0.99

Because of the potential toxicity of mitoxantrone it should be administered under the supervision of a physician experienced in the use of cytotoxic chemotherapeutic agents . In addition patients being treated with mitoxantrone should be monitored routinely for cardiac liver and kidney function abnormalities .

Monitor

1

In patients with PAH serial determinations of functional class and exercise capacity assessed by the 6-minute walk test provide benchmarks for disease severity response to therapy and progression.

Employers and their health and safety personnel should ensure that when respiratory protective equipment is worn the appropriate type is used and maintained fit testing is performed and workers understand how to wear remove and replace their respiratory protective equipment.

Refer/Consult

0.7

A Young adults engaged in demanding physical activities with a first traumatic shoulder dislocation should be referred for orthopaedic evaluation.

Prescribe

1

The guideline developers suggest the initiation of oral anticoagulation with doses between 5 and 10 mg for the first 1 or 2 days for most individuals with subsequent dosing based on the international normalized ratio (INR) .

Prescribe

1

For AF occurring shortly after open-heart surgery and lasting >48 hours the guideline developers suggest anticoagulation with an oral VKA such as warfarin if bleeding risks are acceptable (Grade 2C). The target INR is 2.5 (range 2.0 to 3.0). The guideline developers suggest continuing anticoagulation for several weeks following reversion to normal sinus rhythm (NSR) particularly if patients have risk factors for thromboembolism.

Prescribe

1

For patients aged <75 years with preserved renal function (creatinine <2.5 mg/dL in male and <2.0 mg/dL in female patients) the guideline developers suggest use of enoxaparin (30-mg bolus IV followed by 1 mg/kg SC every 12 hours) with tenecteplase up to 7 days.

Prescribe

1

UFH or LMWH (as above) until the thirteenth week change to warfarin until the middle of the third trimester and then restart UFH or LMWH .

Test

1

Continue to evaluate the child's renal status (urinalysis and culture as indicated) if a renal anomaly is present.

Advocate with parents to school personnel about appropriate educational and therapeutic strategies including: physical occupational and speech therapy; nursing; and adaptive and assistive technology.

Prescribe

1

The most commonly used taxane-based regimens in North America have been administered on a three-weekly schedule and include: i) docetaxel 75 mg/m2 with cisplatin 75 mg/m2 ii) paclitaxel 225 mg/m2 as a 3-hour infusion with carboplatin area under the curve (AUC) 6 and iii) paclitaxel 135 mg/m2 as a 24-hour infusion with cisplatin 75 mg/m2. However there have been few direct comparisons of different doses and schedules for taxane-based combinations and firm recommendations regarding optimal doses and schedules cannot be made at this time.

Prepare

1

States that implement newborn screening for CF should collect follow-up data in collaboration with CF care centers and analyze this information to monitor and improve the quality of CF newborn screening. In particular states should collect share and analyze data by using standard protocols to evaluate and optimize laboratory algorithms used to screen for CF and refer for diagnosis. States seeking guidance on optimal laboratory protocols might wish to consult with states having more experience in conducting CF screening of newborns.

Educate/Counsel

0.89

This assessment should integrate the evidence presented in this guideline with the clinical judgement and expertise of the dental team and should be discussed with the patient.

Prescribe

1

Tricyclic antidepressants (amitriptyline nortriptyline desipramine and maprotiline) gabapentin pregabalin opioids and topical lidocaine patches are effective and should be used in the treatment of postherpetic neuralgia.

Prescribe

0.99

Aerobic gram-positive cocci (especially Staphylococcus aureus) are the predominant pathogens in diabetic foot infections. Patients who have chronic wounds or who have recently received antibiotic therapy may also be infected with gram-negative rods and those with foot ischemia or gangrene may have obligate anaerobic pathogens.

Conclude

1

When deciding whether to recommend the initiation of nPEP to the survivor the clinician should assess and carefully weigh the following factors:Whether or not a significant exposure has occurred during the assaultKnowledge of the HIV status of the alleged assailantWhether the survivor is ready and willing to complete the nPEP regimen

Prescribe

1

The drug regimen of choice is currently unknown because no randomized comparative trials have been conducted in this patient population. Options include tenofovir emtricitabine interferon alfa-2b lamivudine or adefovir; there are insufficient data to recommend combinations of drugs at this time. If lamivudine is given for treatment of hepatitis B it should never be used alone but in combination with other HIV-active antiretroviral agents as a component of highly active antiretroviral therapy (HAART).

Prescribe

1

Recommended Regimens For Post-Exposure Prophylaxis for children 13 years or younger the suggested PEP regimen is zidovudine lamivudine and nelfinavir.

Educate/Counsel

1

Pediatricians should promote parental education in pediatric basic life support. Families of children with special health care needs neonatal intensive care unit graduates children who have ready access to water or children who are active in water sports should be especially encouraged to undergo training and should be assisted in obtaining access to the training.

Perform Therapeutic Procedure

1

There is some class I and adequate class II evidence to indicate that paravertebral or extrapleural infusions are effective in improving subjective pain perception and may improve pulmonary function.

Prescribe

1

Sumatriptan nasal spray is effective and should be considered for the acute treatment of migraine in adolescents.

Monitor

1

Benefits and side effects of corticosteroid therapy need to be monitored. Timed function tests pulmonary function tests and age at loss of independent ambulation are useful to assess benefits. An offer of treatment with corticosteroids should include a balanced discussion of potential risks. Potential side effects of corticosteroid therapy (weight gain cushingoid appearance cataracts short stature [i.e. a decrease in linear growth] acne excessive hair growth gastrointestinal symptoms and behavioral changes) also need to be assessed. If excessive weight gain occurs (>20% over estimated normal weight for height over a 12-month period) based on available data it is recommended that the dosage of prednisone be decreased (to 0.5 mg/kg/day with a further decrease after three to four months to 0.3 mg/kg/day if excessive weight gain continues).

Educate/Counsel

0.33

Benefits and side effects of corticosteroid therapy need to be monitored. Timed function tests pulmonary function tests and age at loss of independent ambulation are useful to assess benefits. An offer of treatment with corticosteroids should include a balanced discussion of potential risks. Potential side effects of corticosteroid therapy (weight gain cushingoid appearance cataracts short stature [i.e. a decrease in linear growth] acne excessive hair growth gastrointestinal symptoms and behavioral changes) also need to be assessed. If excessive weight gain occurs (>20% over estimated normal weight for height over a 12-month period) based on available data it is recommended that the dosage of prednisone be decreased (to 0.5 mg/kg/day with a further decrease after three to four months to 0.3 mg/kg/day if excessive weight gain continues).

Prescribe

0.53

The use of prostaglandins for cervical ripening or induction of labor in most women with a previous cesarean delivery should be discouraged.

Conclude

0.99

Recent food intake is not a contraindication for administering procedural sedation and analgesia but should be considered in choosing the timing and target level of sedation.

Prepare

1

The clinician should have an awareness and understanding of the operations of the juvenile correctional facility and the issues affecting it including the interface with multiple systems (e.g. police probation family/juvenile courts social services and child welfare agencies) and the existing educational and health care systems within the facility .

Educate/Counsel

0.9

Nurses develop skills to foster an environment that facilitates disclosure.This necessitates that nurses know how to ask a question and how to respond.This necessitates that nurses know:how to ask the questionhow to respond

Educate/Counsel

1

Coaches at all levels including youth sports should encourage wholesome and fair competition by emphasizing healthy nutrition and training practices taking a strong stand against cheating and avoiding the win-at-all-costs philosophy.

Perform Therapeutic Procedure

0.96

Incorporate resistance training as an integral part of an adult fitness program. The training should be individualized and progressive should be of sufficient intensity to enhance strength and muscular endurance and should provide stimulus to exercise all the major muscle groups to pain-free fatigue.

Prescribe

1

Erythropoietin is recommended as a reasonable treatment option in patients in whom a slow decline in hemoglobin is associated with increased fatigue and perceived reductions in quality of life.

Test

1

Decision-making parameters for specific preoperative tests or for the timing of preoperative tests cannot be unequivocally determined from the available scientific literature. Further research is needed preferably in the form of appropriately randomized clinical trials. Specific tests and their timing should be individualized and based upon information obtained from sources such as the patient's medical record patient interview physical examination and the type and invasiveness of the planned procedure.

Test

0.92

Nurses will assess and evaluate vascular access devices for occlusion in order to facilitate treatment and improve client outcomes.

Inquire

1

Clinicians giving women information on contraceptive options should enquire about current and previous drug use; prescription nonprescription and herbal drug use; and specifically about use of drugs which induce liver enzymes and non-liver enzyme-inducing antibiotics.

Educate/Counsel

1

Provide education for the child and family on the diagnosis of JFMS interrelationship of symptoms and management of symptoms. Provide education to the child and family on an ongoing basis to increase self-care skills improve self-efficacy and enhance understanding of the interrelationships between pain mood stress exercise and the role of factors concerning the parental and family environment. Include background information regarding the prevalence of pain in children.

Educate/Counsel

1

The public should be informed that UI is not inevitable or shameful. UI is treatable and if not it is manageable. Patient education should be individualised involving caregivers and others.

Prescribe

0.98

Levels of LNG in breast milk are low with the LNG-IUS. Therefore women who are breastfeeding and are 4 or more weeks postpartum may choose this method .

Monitor

0.74

Children with tyrosinemia who develop hepatocellular carcinoma (HCC) and meet the criteria for liver transplantation for HCC should be high-priority candidates .

Perform Therapeutic Procedure

1

There are no current recommendations for bright light therapy related to insufficient evidence supporting its use .In the elderly population exposure to bright outdoor sunlight (preferably in the late afternoon or early evening) can improve alertness motivation sleep quality and mood.

Prescribe

1

Atenolol gabapentin (monotherapy) sotalol and topiramate should be considered as treatment of limb tremor associated with ET. Alprazolam is recommended with caution due to its abuse potential . Propranolol should be considered as treatment of head tremor in patients with ET.

Prepare

1

Be aware of options and resources for adolescents and advocate for comprehensive medical and psychosocial support for all pregnant adolescents in the community.

Refer/Consult

1

Nurses in all practice settings should screen clients for evidence of depression using a validated tool (such as the Stroke Aphasia Depression Questionnaire Geriatric Depression Scale Hospital Anxiety and Depression Scale or the Cornell Scale for Depression in Dementia) prior to discharge throughout the continuum of care. In situations where evidence of depression is identified clients should be referred to a trained healthcare professional for further assessment and management.

Monitor

0.6

Nurses in all practice settings should screen clients for evidence of depression using a validated tool (such as the Stroke Aphasia Depression Questionnaire Geriatric Depression Scale Hospital Anxiety and Depression Scale or the Cornell Scale for Depression in Dementia) prior to discharge throughout the continuum of care. In situations where evidence of depression is identified clients should be referred to a trained healthcare professional for further assessment and management.

Educate/Counsel

0.23

Clinicians should reassess potential barriers to adherence at least every 3 to 4 months and whenever adherence problems are identified.

Prescribe

1

For patients undergoing laparoscopic procedures and who have additional thromboembolic risk factors the guideline developers recommend the use of thromboprophylaxis with one or more of the following: LDUH LMWH IPC or GCS.

Test

1

In women for whom treatment options are restricted to tamoxifen or hormone therapy or for whom no further treatment is indicated because of age or other factors routine bone scanning liver ultrasonography and chest radiography are not indicated as part of baseline staging.

Prescribe

1

In selected patients (e.g. those with good performance status less than 70 years of age and with no other major comorbidities) who are anthracycline-resistant or who have previously received an anthracycline as adjuvant therapy the combination of docetaxel and capecitabine is an appropriate therapeutic option.

Educate/Counsel

0.21

In selected patients (e.g. those with good performance status less than 70 years of age and with no other major comorbidities) who are anthracycline-resistant or who have previously received an anthracycline as adjuvant therapy the combination of docetaxel and capecitabine is an appropriate therapeutic option.

Prescribe

0.38

The routine use of Type 4 PM devices with oximetry and at least one other airflow parameter is not recommended in an attended setting to both increase and decrease the probability that a patient has an AHI greater than 15.

Test

1

Magnetic resonance imaging of the breast (MRIB) is an adjunct to mammography clinical breast examination and ultrasonography for breast cancer detection in women at high risk of breast cancer based on family history or BRCA mutations.

Conclude

0.4

Magnetic resonance imaging of the breast (MRIB) is an adjunct to mammography clinical breast examination and ultrasonography for breast cancer detection in women at high risk of breast cancer based on family history or BRCA mutations.

Prevent

0.23

Magnetic resonance imaging of the breast (MRIB) is an adjunct to mammography clinical breast examination and ultrasonography for breast cancer detection in women at high risk of breast cancer based on family history or BRCA mutations.

Educate/Counsel

0.37

Summary Statement 55. In older adults medications and co-morbid medical conditions may increase the risk from immunotherapy. Therefore special consideration must be given to the benefits and risks of immunotherapy in older adults.

Test

0.87

Treatment for pregnant patients with invasive carcinoma of the cervix should be individualized on the basis of evaluation of maternal and fetal risks.

After progression on first-line anti-thymidylate synthase monotherapy (e.g. 5FU/FA; capecitabine) irinotecan is standard second-line therapy. FOLFOX is a reasonable alternative for patients with contraindications to the use of second-line irinotecan.

Prescribe

1

The aromatase inhibitors anastrozole exemestane and letrozole within their licensed indications are recommended as options for the adjuvant treatment of early oestrogen-receptor-positive invasive breast cancer in postmenopausal women.

Educate/Counsel

1

The decision about which of the procedures (open or laparoscopic) is undertaken should be made after informed discussion between the patient and the surgeon. In particular they should consider:The suitability of the lesion for laparoscopic resectionThe risks and benefits of the two proceduresThe experience of the surgeon in both procedures

Perform Therapeutic Procedure

0.89

Graded assistance practice and positive reinforcement should be used to increase functional independence.

Prescribe

0.97

The effects of PE and intravenous immunoglobulin (IVIg) are equivalent.

Prescribe

1

Preclinical studies did not show any cardioprotectant effect for dexrazoxane when used with mitoxantrone and no clinical studies have been done. Therefore dexrazoxane is not recommended for use with mitoxantrone.

Monitor

0.26

Preclinical studies did not show any cardioprotectant effect for dexrazoxane when used with mitoxantrone and no clinical studies have been done. Therefore dexrazoxane is not recommended for use with mitoxantrone.

Perform Therapeutic Procedure

0.58

Recommendations for surgery based upon tumor size are derived from studies not standardized for inclusion criteria length of follow-up or methods of estimating the risk of carcinoma. Nevertheless patients with tumors greater than 6 cm usually are treated surgically while those with tumors less than 4 cm are generally monitored. In patients with tumors between 4 and 6 cm criteria in addition to size should be considered in making the decision to monitor or proceed to adrenalectomy.

Perform Therapeutic Procedure

1

The optimal use of radiosurgery in the treatment of brain metastases remains to be defined. In patients with one to three brain metastases (less than 3 cm in size) and limited or controlled extracranial disease radiosurgery may be considered to improve local tumour control either as boost therapy with whole brain radiation or at the time of relapse after whole brain radiotherapy.

Inquire

1

It is recommended that diagnostic information be obtained directly from parents/caregivers in the form of questionnaires and an interview that is structured to elicit information about family structure and dynamics parenting styles and expectations and pertinent family educational and psychiatric history.

Educate/Counsel

1

Nurses with experience and expertise in breastfeeding should provide support to mothers. Such support should be established in the antenatal period continued into the postpartum period and should involve face-to-face contact.

Ask what types of work the patient has done and the longest time s/he held a job to identify abilities and interests assess stability and determine risk for comorbidities associated with toxic exposures (e.g. to asbestos silica coal). Ask about any work-related illnesses or injuries and whether they have interfered with gainful activity (i.e. made it difficult to do work resulted in job loss presented obstacles to hiring). If so consult the Association of Occupational and Environmental Clinics for referrals and assistance.

Perform Therapeutic Procedure

1

Women with uncomplicated breech at 37 to 40 weeks should be offered external cephalic version (ECV) to increase the likelihood of cephalic presentation and vaginal birth.

Educate/Counsel

1

The opinions and experiences of lung cancer patients and carers should be collected and used to improve the delivery of lung cancer services. Patients should receive feedback on any action taken as a result of such survey.

Monitor

1

Patients with septic shock should be treated in an intensive care unit with continuous electrocardiographic monitoring and monitoring of arterial oxygenation.

Comply with the International Code of Marketing of Breast-milk Substitutes and subsequent World Health Assembly resolutions and avoid distribution of infant feeding product samples and advertisements for such products.

Test

1

Measurement of fasting cholesterol lipids and triglycerides should be offered to patients with PCOS since early detection of abnormal levels might encourage improvement in diet and exercise.

Test

0.25

Measurement of fasting cholesterol lipids and triglycerides should be offered to patients with PCOS since early detection of abnormal levels might encourage improvement in diet and exercise.

Prescribe

0.75

Prepregnancy suppression of high luteinising hormone (LH) concentration among ovulatory women with recurrent miscarriage and polycystic ovaries who hypersecrete LH does not improve the live birth rate.

Monitor

1

Asymptomatic patients who are referred to healthcare facilities should be monitored for at least 6 hours after ingestion if they took an immediate-release preparation other than sotalol 8 hours if they took a sustained-release preparation and 12 hours if they took sotalol. Routine 24-hour admission of an asymptomatic patient who has unintentionally ingested a sustained-release preparation is not warranted.

Refer/Consult

0.99

A witnessed taste or lick only in a child or an adult who unintentionally drinks and then expectorates all of a concentrated product without swallowing does not need referral .

Prescribe

1

Testosterone therapy without concomitant estrogen therapy cannot be recommended because there are no data on the safety and efficacy of testosterone therapy in women not using concomitant estrogen.

Test

1

For clinicians considering a laboratory blood test to diagnose epileptic seizures (ES)Elevated serum prolactin (PRL) when measured in appropriate clinical setting at 10 to 20 minutes after a suspected event should be considered a useful adjunct to differentiate generalized tonic-clonic seizures or complex partial seizures from psychogenic nonepileptic seizures among adults and older children.

Perform Therapeutic Procedure

1

Carotid endarterectomy (CE) is established as effective for recently symptomatic (within previous 6 months) patients with 70 to 99% internal carotid artery (ICA) angiographic stenosis .CE should not be considered for symptomatic patients with less than 50% stenosis . CE may be considered for patients with 50 to 69% symptomatic stenosis but the clinician should consider additional clinical and angiographic variables. It is recommended that the patient have at least a 5-year life expectancy and that the perioperative stroke/death rate should be <6% for symptomatic patients .Medical management is preferred to CE for symptomatic patients with <50% stenosis .

Educate/Counsel

1

A program for the purpose of gaining or losing weight should (a) be started early to permit a gradual weight gain or loss over a realistic time period (b) permit a change of 1.5% or less of one's body weight per week (c) permit the loss of weight to be fat loss and the gain of weight to be muscle mass (d) be coupled with an appropriate training program (both strength and conditioning) and (e) incorporate a well-balanced diet with adequate energy (calories) carbohydrates protein and fat. After athletes obtain their desired weight they should be encouraged to maintain a constant weight and avoid fluctuations of weight. A weight-loss plan for athletic purposes should never be instituted before the 9th grade.

Perform Therapeutic Procedure

0.78

A program for the purpose of gaining or losing weight should (a) be started early to permit a gradual weight gain or loss over a realistic time period (b) permit a change of 1.5% or less of one's body weight per week (c) permit the loss of weight to be fat loss and the gain of weight to be muscle mass (d) be coupled with an appropriate training program (both strength and conditioning) and (e) incorporate a well-balanced diet with adequate energy (calories) carbohydrates protein and fat. After athletes obtain their desired weight they should be encouraged to maintain a constant weight and avoid fluctuations of weight. A weight-loss plan for athletic purposes should never be instituted before the 9th grade.

Prescribe

0.22

Laparoscopic surgery is recommended as an acceptable option for the treatment of stage I II or III colon cancer and should be considered an alternative to conventional open surgery for colon cancer in specified patients.

Prepare

0.6

Assess patient/caregiver ability and compliance for outpatient therapy and need for home care resources.

Perform Therapeutic Procedure

0.99

Weight loss surgery should be considered only for patients in whom other methods of treatment have failed and who have clinically severe obesity (i.e. BMI >40 or BMI >35 with life-threatening comorbid conditions.

Refer/Consult

1

Clinicians should refer patients with HAD who present with accompanying depression mania psychosis behavioral disturbance or substance use for psychiatric consultation to assist in psychopharmacologic treatment and management.

Perform Therapeutic Procedure

1

Surgery is indicated in patients who fail or are unable to comply with medical therapy and may be combined with cataract removal for enhanced visual rehabilitation .

Perform Therapeutic Procedure

0.93

The best initial treatment for the fetus is the provision of optimum resuscitation of the mother and the early assessment of the fetus.

Prescribe

1

People satisfying the conditions in the first two recommendations (see above) but for whom ribavirin is contraindicated or is not tolerated should be treated with peginterferon alfa monotherapy. Regardless of genotype individuals should be tested for viral load at 12 weeks and if the viral load has reduced to less than 1% of its level at the start of treatment treatment should be continued for a total of 48 weeks. If viral load has not fallen to this extent treatment should stop at 12 weeks.

Monitor

1

Treatment should be reviewed at regular intervals to ensure that children with epilepsy are not maintained for long periods on treatment that is ineffective or poorly toleratedand that concordance with prescribed medication is maintained.

Prescribe

1

Patients with severe and/or refractory cough due to asthma should receive a short course (1 to 2 weeks) of systemic (oral) corticosteroids followed by inhaled corticosteroids.

Conclude

1

In a patient with an acute respiratory infection manifested predominantly by cough with or without sputum production lasting no more than 3 weeks a diagnosis of acute bronchitis should not be made unless there is no clinical or radiographic evidence of pneumonia and the common cold acute asthma or an exacerbation of chronic obstructive pulmonary disease (COPD) have been ruled out as the cause of cough.

Test

0.88

In patients with cough in whom more common causes have been excluded because bacterial suppurative airways disease may be present and clinically unsuspected bronchoscopy is required before excluding it as a cause.

Prescribe

0.99

For patients with cough and lung cancer the use of centrally acting cough suppressants such as dihydrocodeine and hydrocodone is recommended.

Prescribe

1

In patients whose cough resolves after the cessation of therapy with ACE inhibitors and for whom there is a compelling reason to treat with these agents a repeat trial of ACE inhibitor therapy may be attempted.

Prescribe

0.92

In patients with cough secondary to sarcoidosis although therapy with oral corticosteroids may lead to symptomatic improvement as they have not been proven to have a durable benefit and are associated with significant side effects an individualized analysis of the overall benefit and risk is necessary.

Test

1

In patients with immune deficiency the initial diagnostic algorithm for patients with acute subacute and chronic cough is the same as that for immunocompetent persons taking into account an expanded list of differential diagnoses that considers the type and severity of immune defect and geographic factors.

Test

1

Children with chronic cough should undergo as a minimum a chest radiograph and spirometry (if age appropriate).

Inquire

1

In the office setting calcium intake can be assessed periodically with a simple questionnaire. Suggested ages for screening are 2 to 3 years of age after the transition from human milk or formula; 8 to 9 years of age during preadolescence; and again during adolescence when the peak rate of bone mass accretion occurs. Targeted questions are suggested .

Test

0.85

Clinicians should assess adherence and be alert for signs of hepatotoxicity in HIV-infected patients receiving HAART who are concurrently using recreational drugs.

Prescribe

1

Clinicians should not withhold treatment for pain because a patient has a history of substance use. Rather standard pain assessment and treatment protocols should be followed.

Document

0.8

Retinal examinations in preterm infants should be performed by an ophthalmologist who has sufficient knowledge and experience to enable accurate identification of the location and sequential retinal changes of ROP. The International Classification of Retinopathy of Prematurity Revisited (International Committee for the Classification of Retinopathy of Prematurity 2005) should be used to classify diagram and record these retinal findings at the time of examination.

Prevent

0.5

Retinal examinations in preterm infants should be performed by an ophthalmologist who has sufficient knowledge and experience to enable accurate identification of the location and sequential retinal changes of ROP. The International Classification of Retinopathy of Prematurity Revisited (International Committee for the Classification of Retinopathy of Prematurity 2005) should be used to classify diagram and record these retinal findings at the time of examination.

Prescribe

0.5

Adolescents 11 to 18 years of age should receive a single dose of Tdap instead of tetanus and diphtheria toxoids (Td) vaccine for booster immunization against tetanus diphtheria and pertussis if they have completed the recommended childhood diphtheria tetanus and pertussis (DTP)/diphtheria and tetanus toxoids and acellular pertussis (DTaP) immunization series* and have not received Td; the preferred age for Tdap immunization is 11 to 12 years.

Test

1

When reporting results of immunoassay screening there must be proper notation given that the assay used is considered as a screening test'' and that any positive results are to be considered as presumptive''.

Prescribe

1

The following recommendations are based on good and consistent scientific evidence (Level A):The two 0.75-mg doses of the levonorgestrel-only regimen are equally effective if taken 12-24 hours apart.

Conclude

1

The decision regarding which product to use should be based on the following:the presence of comorbid conditions (for example tic disorders Tourette's syndrome epilepsy)the different adverse effects of the drugsspecific issues regarding compliance identified for the individual child or adolescent for example problems created by the need to administer a mid-day treatment dose at schoolthe potential for drug diversion (where the medication is forwarded on to others for non-prescription uses) and/or misusethe preferences of the child/adolescent and/or his or her parent or guardian.

Prescribe

1

Adefovir dipivoxil should not normally be given before treatment with lamivudine. It may be used either alone or in combination with lamivudine when:treatment with lamivudine has resulted in viral resistance orlamivudine resistance is likely to occur rapidly (for example in the presence of highly replicative hepatitis B disease) and development of lamivudine resistance is likely to have an adverse outcome (for example if a flare of the infection is likely to precipitate decompensated liver disease).

Conclude

1

Of the drugs available for the treatment of acute mania the choice of which to prescribe should be made jointly by the individual and the clinician(s) responsible for treatment. The choice should be based on an informed discussion of the relative benefits and side-effect profiles of each drug and should take into account the needs of the individual and the particular clinical situation.

Educate/Counsel

1

Valid consent should be obtained in all cases where the individual has the ability to grant or refuse consent.The decision to use ECT should be made jointly by the individual and the clinician(s) responsible for treatment on the basis of an informed discussion. This discussion should be enabled by the provision of full and appropriate information about the general risks associated with ECT and about the risks and potential benefits specific to that individual. Consent should be obtained without pressure or coercion which may occur as a result of the circumstances and clinical setting and the individual should be reminded of their right to withdraw consent at any point. There should be strict adherence to recognised guidelines about consent and the involvement of patient advocates and/or carers to facilitate informed discussion is strongly encouraged.

Conclude

1

It is recommended that in determining who is at high risk clinicians should take into account combinations of risk factors such as: clinical history including age previous MI and previous PCI or CABG; clinical signs including continuing pain despite initial treatment; and clinical investigations such as electrocardiogram (ECG) changes (particularly dynamic or unstable patterns indicating myocardial ischaemia) haemodynamic changes and raised cardiac troponin levels .

Test

1

Preoperative spirometry and chest radiography should not be used routinely for predicting risk for postoperative pulmonary complications.Preoperative pulmonary function testing or chest radiography may be appropriate in patients with a previous diagnosis of chronic obstructive pulmonary disease or asthma.

Educate/Counsel

0.78

Identify resources and supports to assist families address the life event whether this is expected or unexpected. Resources should be identified within the following three categories:IntrafamilialInterfamilialExtrafamilial

Prepare

1

The principles of client centred care should be included in the basic education of nurses in their core curriculum be available as continuing education be provided in orientation programs and be sustained through professional development opportunities in the organization. Organizations should engage all members of the healthcare team in this ongoing education process.

Prescribe

1

Single-agent pemetrexed (Alimta) at a dose of 500 mg/m2 every three weeks is also an option for second-line therapy of recurrent or progressive disease if available. This chemotherapy should be administered with vitamin supplements: oral folic acid 350-1 000 micrograms daily and intramuscular vitamin B12 1 000 micrograms every nine weeks beginning between one to two weeks before and continuing until three weeks after chemotherapy.

Conclude

1

Distinguish between acute otitis media (AOM) and otitis media with effusion (OME) in making therapeutic decisions.

Prepare

0.98

Legislation in Europe is heterogeneous but where it has relevance to AEDs it either has permitted or is likely to permit their use by nonmedically qualified first responders. Automated external defibrillation does not require establishing a clinical diagnosis and therefore it should be lifted from the list of actions reserved to doctors. Slow implementation is mainly the result of limited perception of the importance of early defibrillation programmes and by traditions and reluctance to de-medicalise the act of defibrillation. The lack of data on cost-effectiveness may discourage the support of governments for AED programmes. Therefore this type of economical evaluation should be part of any planned developments. European legislation or recommendation issued by European policy makers and supported by all relevant major health care and scientific societies could promote implementation of this life saving strategy that is strongly supported by scientific evidence.

Prevent

0.3

Legislation in Europe is heterogeneous but where it has relevance to AEDs it either has permitted or is likely to permit their use by nonmedically qualified first responders. Automated external defibrillation does not require establishing a clinical diagnosis and therefore it should be lifted from the list of actions reserved to doctors. Slow implementation is mainly the result of limited perception of the importance of early defibrillation programmes and by traditions and reluctance to de-medicalise the act of defibrillation. The lack of data on cost-effectiveness may discourage the support of governments for AED programmes. Therefore this type of economical evaluation should be part of any planned developments. European legislation or recommendation issued by European policy makers and supported by all relevant major health care and scientific societies could promote implementation of this life saving strategy that is strongly supported by scientific evidence.

Perform Therapeutic Procedure

0.53

Early mobilisation and leg exercises should be encouraged in patients recently immobilised.

Prescribe

1

It is recommended that antihistamines oral decongestants and nasal vasoconstrictors not be used for routine therapy.

Inquire

1

It is recommended that for a child with ABS physicians explore parental expectations concerning the office visit parental knowledge regarding respiratory infections and preventive behavior .

Prescribe

1

If symptom control and/or quality of life are the outcomes of interest for a patient chemotherapy is a reasonable option which may improve quality of life and reduce disease-related symptoms.

Inquire

1

Accurate history taking by emergency responders and medical personnel at the time of death and immediate transmission of this historical information to the medical examiner or coroner.

Perform Therapeutic Procedure

1

Regardless of surgical staging adjuvant external beam radiotherapy is recommended for patients at high risk of recurrenceis not recommended in patients at low risk of recurrenceis a reasonable treatment option for patients at intermediate risk of recurrenceTwo randomized trials detected that adjuvant external beam radiotherapy improved pelvic control but not survival when compared to no further treatment.In patients with no adjuvant therapy salvage radiotherapy may be effective upon vaginal recurrence.When considering adjuvant radiotherapy the potential improvement in pelvic control needs to be weighed against the toxicity of radiotherapy.Radiotherapy was associated with a low incidence of severe acute and late adverse effects; however many patients experienced mild (grade 1 or 2) side effects. The long-term effects of radiotherapy are unknown at this time.

Prescribe

1

Among patients with a cryptogenic stroke and atrial septal abnormalities there is insufficient evidence to determine the superiority of aspirin or warfarin for prevention of recurrent stroke or death.

Test

1

Static lumbar radiographs are not recommended as a stand-alone means to assess fusion status following lumbar arthrodesis surgery.

Test

1

Exercise testing is not recommended as part of routine evaluation in patients with HF. Specific circumstances in which maximal exercise testing with measurement of expired gases should be considered include:Assessing disparity between symptomatic limitation and objective indicators of disease severity.Distinguishing non HF-related causes of functional limitation specifically cardiac versus pulmonary.Considering candidacy for cardiac transplantation or mechanical intervention.Determining the prescription for cardiac rehabilitation.Addressing specific employment capabilities.Exercise testing with physiologic testing for inducible abnormality in myocardial perfusion or wall motion abnormality should be considered to screen for the presence of coronary artery disease with inducible ischemia.

Prevent

1

Anesthetic agents such as propofol and sedation adjuncts such as droperidol promethazine and diphenhydramine are useful in certain patients undergoing endoscopic procedures. While propofol provides faster onset and deeper sedation than standard benzodiazepines and narcotics as well as faster recovery clinically important benefits have not been consistently demonstrated in average-risk patients undergoing standard upper and lower endoscopy

Test

1

Screening for autonomic neuropathy should be instituted at diagnosis of type 2 diabetes and 5 years after the diagnosis of type 1 diabetes. Special electrophysiological testing for autonomic neuropathy is rarely needed and may not affect management and outcomes.

Perform Therapeutic Procedure

0.29

Gastric residual values and tolerance.

Educate/Counsel

0.38

Provide consistent and appropriate care and follow-up in presence of a medication-related problem.

Prescribe

1

ACTH is probably effective for the short-term treatment of infantile spasms and in resolution of hypsarrhythmia .

Perform Therapeutic Procedure

1

It is recommended that the decision to undertake surgical intervention for severe heart failure (HF) be made in light of functional status and prognosis based on severity of underlying HF and comorbid conditions. Procedures should be done at centers with demonstrable expertise and multidisciplinary medical and surgical teams experienced in the selection care and perioperative and long-term management of high risk patients with severe HF.

The addition of moderate-dose interferon-alpha 2b has produced a significantly higher response rate than single-agent temozolomide in a large randomized phase III study. However overall survival was not altered and grade 3 and 4 hematologic toxicities were higher with the combined treatment. At the present time the addition of interferon-alpha to temozolomide is not recommended.

Prescribe

1

Adverse effects may occur with androgen replacement therapy at supraphysiologic levels. Acne hirsutism and a significant reduction in high-density lipoprotein (HDL) cholesterol levels have been described

Prepare

0.97

The Task Force recommends against screening for androgen deficiency in the general population.

Patients who have previously received rituximab and who have achieved a response of at least one year's duration to the last rituximab administration and who are appropriate candidates for chemotherapy should receive this chemotherapy in combination with rituximab.

Prescribe

1

Purine analogues are appropriate for the initial and subsequent treatment of Waldenstrom's Macroglobulinaemia. There is no consensus on the duration of treatment with cladribine or fludarabine or on which purine analogue is superior. Fludarabine is more active than cyclophosphamide doxorubicin and prednisolone (CAP) as salvage therapy.

Educate/Counsel

1

Minimize dietary restrictions. Salt and fat contributes to the taste in food and a regular diet does not significantly affect glucose control. Both adjustments to the diet may make meals more delectable and savory and therefore increase overall food intake.

Perform Therapeutic Procedure

1

Where surgery is required radiotherapy should also be given and the timing of surgery relative to radiotherapy should be determined for each patient .

Prepare

0.24

Where surgery is required radiotherapy should also be given and the timing of surgery relative to radiotherapy should be determined for each patient .

Prevent

0.39

Where surgery is required radiotherapy should also be given and the timing of surgery relative to radiotherapy should be determined for each patient .

Educate/Counsel

0.37

Public health programs and primary care providers should adopt strategies appropriate for the practice setting to ensure that all adults at risk for HBV infection are offered hepatitis B vaccine.

Prescribe

0.74

Omalizumab is more effective than placebo at helping to reduce or withdraw inhaled steroids and at reducing asthma exacerbations .

Test

0.89

Parameters of Assessment:Assess for intrinsic and extrinsic risk factorsBraden Scale-cutscore (at risk)18 or below for elderly and persons with darkly pigmented skin16 or below for other adults.

Prevent

1

Not Contraindications or Precautions for Tdap:The following conditions are not contraindications or precautions for Tdap and adults with these conditions may receive a dose of Tdap if otherwise indicated. The conditions in italics are precautions for pediatric DTP/DTaP but are not contraindications or precautions for Tdap vaccination in adults ( Pertussis vaccination 1997).Temperature >105 degrees F (>40.5 degrees C) within 48 hours after pediatric DTP/DTaP not attributable to another causeCollapse or shock-like state (hypotonic hyporesponsive episode) within 48 hours after pediatric DTP/DTaPPersistent crying lasting >3 hours occurring within 48 hours after pediatric DTP/DTaPConvulsions with or without fever occurring within 3 days after pediatric DTP/DTaPStable neurologic disorder including well-controlled seizures a history of seizure disorder that has resolved and cerebral palsy (See section Safety Considerations for Adult Vaccination with Tdap in the original guideline document)Brachial neuritisImmunosuppression including persons with human immunodeficiency virus (HIV). The immunogenicity of Tdap in persons with immunosuppression has not been studied and could be suboptimal.BreastfeedingIntercurrent minor illnessUse of antimicrobialsHistory of an extensive limb swelling (ELS) reaction following pediatric DTP/DTaP or Td that was not an Arthus hypersensitivity reaction (see Safety Considerations for Adult Vaccination with Td section in the original guideline document for descriptions of ELS and Arthus reactions).

Perform Therapeutic Procedure

0.77

Not Contraindications or Precautions for Tdap:The following conditions are not contraindications or precautions for Tdap and adults with these conditions may receive a dose of Tdap if otherwise indicated. The conditions in italics are precautions for pediatric DTP/DTaP but are not contraindications or precautions for Tdap vaccination in adults ( Pertussis vaccination 1997).Temperature >105 degrees F (>40.5 degrees C) within 48 hours after pediatric DTP/DTaP not attributable to another causeCollapse or shock-like state (hypotonic hyporesponsive episode) within 48 hours after pediatric DTP/DTaPPersistent crying lasting >3 hours occurring within 48 hours after pediatric DTP/DTaPConvulsions with or without fever occurring within 3 days after pediatric DTP/DTaPStable neurologic disorder including well-controlled seizures a history of seizure disorder that has resolved and cerebral palsy (See section Safety Considerations for Adult Vaccination with Tdap in the original guideline document)Brachial neuritisImmunosuppression including persons with human immunodeficiency virus (HIV). The immunogenicity of Tdap in persons with immunosuppression has not been studied and could be suboptimal.BreastfeedingIntercurrent minor illnessUse of antimicrobialsHistory of an extensive limb swelling (ELS) reaction following pediatric DTP/DTaP or Td that was not an Arthus hypersensitivity reaction (see Safety Considerations for Adult Vaccination with Td section in the original guideline document for descriptions of ELS and Arthus reactions).

Prescribe

0.23

Antidepressant Treatment of Pain-predominant IBS:Selective serotonin reuptake inhibitors (SSRIs) (Recommendation I Quality Poor)CitalopramEscitalopram oxalateFluoxetineSertralineParoxiteneA pilot open-label study suggested that paroxetine is effective in reducing pain and other IBS symptoms. A literature search revealed only one randomized controlled trial (RCT) examining the use of an SSRI (paroxetine) for treatment of IBS. This trial did suggest an improvement in overall well-being in both depressed and non-depressed individuals with IBS. Given the limited evidence their use is not recommended as routine or first-line therapy except in patients who also have co-morbid depression.

Prescribe

1

Women who have not undergone optimal surgical staging can be offered two options. The first option is that they undergo reoperation to optimally define the tumour stage and then be offered adjuvant therapy based on the findings. The other option is that they be offered platinum-based chemotherapy to decrease the risk of recurrence and improve survival.

Test

0.5

Women who have not undergone optimal surgical staging can be offered two options. The first option is that they undergo reoperation to optimally define the tumour stage and then be offered adjuvant therapy based on the findings. The other option is that they be offered platinum-based chemotherapy to decrease the risk of recurrence and improve survival.

Educate/Counsel

0.21

Treatment of Hepatitis C Infection:Treatment for HCV should be considered for all patients co-infected with HIV and HCV.

Perform Therapeutic Procedure

1

Of those trials designed to improve therapeutic ratios in patients with locally advanced unresectable stage III non-small cell lung cancer there is insufficient data of high quality to recommend hyperfractionation over standard radiotherapy of 60 Gy in 30 fractions. Further randomized controlled trials are necessary to confirm the benefits if any of hyperfractionation radiotherapy.

Educate/Counsel

1

Discuss Treatments.Once patients have a better understanding of their headache type it is important to include them in the treatment decision process. In many cases it is beneficial to explain that even though there is no cure for headache with proper treatment headaches can be effectively managed. Be sure to spend adequate time discussing all the possible treatment options and any potential side effects. Be specific when explaining proper medication use including correct dosing when to treat the frequency of medication usage and how and when to use rescue medications if appropriate. Educate patients about nonpharmacologic treatments including behavior modification a healthy diet and exercise. Set realistic treatment expectations and encourage patients to take responsibility for their treatment. Allow for a question and answer period before ending the visit.

Refer/Consult

1

Assessors and Multidisciplinary Teams:: Assessors of older people should be part of (or have ready access to) a wider multidisciplinary team (MDT) to whom they can quickly refer the older person for more in-depth assessment or for help in any particular domain.

Prevent

1

Trivalent Inactivated Influenza Vaccine (TIV) Indications:Young healthy children are at high risk of hospitalization for influenza infection; therefore the American Academy of Pediatrics recommends influenza immunization of healthy children between 6 and 24 months of age . This applies to any child who will be 6 through 23 months of age at any time during the influenza season which extends from the beginning of October through March. Children should not be immunized before they reach 6 months of age. Influenza immunization of household contacts and out-of- home caregivers of children younger than 24 months of age also is recommended (evidence grade III). Immunization of close contacts of children younger than 6 months may be particularly important because these infants will not be immunized.

Test

1

Single-Photon Emission Computed Tomography (SPECT) and Positron Emission Tomography (PET):If attacks can be fully accounted for by the standard headache classification (International Headache Society) a PET or SPECT scan will generally be of no further diagnostic value. Nuclear medicine examinations of cerebral circulation and metabolism can be carried out in subgroups of headache patients for diagnosis and evaluation of complications. Regional cerebral blood flow (rCBF) recordings can be of particular value in patients in whom the standard classification (International Headache Society) cannot be fully applied when patients experience unusually severe attacks or the quality or severity of attacks has changed. rCBF recordings should then be carried out both during an attack (if possible several repeated scans) and interictally (at a time interval of >5 days after an attack). Quantifiable rCBF measurements are preferable to distribution images.

Test

1

Studies of Skin Reinnervation:Skin biopsy with quantification of IENF density can be used to assess the regeneration rate of sensory axons in peripheral neuropathies and could represent a potential outcome measure in clinical trials .

Patients with HF especially those on diuretic therapy and restricted diets should be considered for daily multivitamin-mineral supplementation to ensure adequate intake of the recommended daily value of essential nutrients. Evaluation for specific vitamin or nutrient deficiencies is rarely necessary.

Prescribe

0.97

Cocaine Use Disorders: Treatment Principles and Alternatives:Management of Intoxication and WithdrawalCocaine intoxication is usually self-limited and typically requires only supportive care . However hypertension tachycardia seizures and persecutory delusions can occur with cocaine intoxication and may require specific treatment.

Educate/Counsel

1

Patients with Substance Use Disorder:Patient Education and Intervention by Primary Care Physician (PCP) or Trained Staff (e.g. RN MSW).Discuss the relationship to presenting medical concerns or psychosocial problems.Assess the patient's readiness to change.Negotiate goals and strategies for reducing consumption and other change.Involve family members as appropriate.Schedule a follow-up -- at least 2 visits within 30 days after starting treatment.

Test

1

Staging: Patients with small peripheral tumours and a negative CT scan of the mediastinum require no further investigation. Otherwise it is reasonable to further investigate the mediastinum with mediastinoscopy or PET prior to performing a thoracotomy.

Perform Therapeutic Procedure

1

Surgery Laser Photodynamic Therapy and Cryotherapy:Adult Female Anogenital Lichen Sclerosus:There is no indication for removal of vulval tissue in the management of uncomplicated LS and surgery should be used exclusively for malignancy and postinflammatory sequelae.In one study nine of 12 patients with severe itch due to vulval LS unresponsive to topical treatment responded to cryotherapy 50% for 3 years.

Test

0.41

Surgery Laser Photodynamic Therapy and Cryotherapy:Adult Female Anogenital Lichen Sclerosus:There is no indication for removal of vulval tissue in the management of uncomplicated LS and surgery should be used exclusively for malignancy and postinflammatory sequelae.In one study nine of 12 patients with severe itch due to vulval LS unresponsive to topical treatment responded to cryotherapy 50% for 3 years.

Conclude

0.58

Functional abdominal pain generally can be diagnosed correctly by the primary care clinician in children 4 to 18 years of age with chronic abdominal pain when there are no alarm symptoms or signs the physical examination is normal and the stool sample tests are negative for occult blood without the requirement of additional diagnostic evaluation.

Perform Therapeutic Procedure

0.97

The optimal fractionation schedule for breast irradiation has not been established and the role of boost irradiation is unclear. Outside of a clinical trial two commonly used fractionation schedules are suggested: 50 Gy in 25 fractions to the whole breast or 40 Gy in 16 fractions to the whole breast with a local boost to the primary site of 12.5 Gy in five fractions. Shorter schedules (e.g. 40 or 44 Gy in 16 fractions) have also been used routinely in some centres. The enrolment of patients in ongoing clinical trials is encouraged.

Recognize the signs and symptoms of pesticide exposures (both acute and chronic).

Educate/Counsel

0.9

The decision to include bevacizumab in 5-FU-based regimens requires discussion with the patient regarding risks of added toxicity and potential benefit.

Perform Therapeutic Procedure

1

Low-carbohydrate diets are not recommended in the management of diabetes. Although dietary carbohydrate is the major contributor to postprandial glucose concentration it is an important source of energy water-soluble vitamins and minerals and fiber. Thus in agreement with the National Academy of Sciences-Food and Nutrition Board a recommended range of carbohydrate intake is 45-65% of total calories. In addition because the brain and central nervous system have an absolute requirement for glucose as an energy source restricting total carbohydrate to <130 grams/day is not recommended

Perform Therapeutic Procedure

1

What to Give in Hospital and the Community:Nutrition support should be cautiously introduced in seriously ill or injured people requiring enteral tube feeding or parenteral nutrition. It should be started at no more than 50% of the estimated target energy and protein needs. It should be built up to meet full needs over the first 24 to 48 hours according to metabolic and gastrointestinal tolerance. Full requirements of fluid electrolytes vitamins and minerals should be provided from the outset of feeding.

Monitor

1

Women at Average Risk:For women in their 20s and 30s it is recommended that clinical breast examination (CBE) be part of a periodic health examination preferably at least every three years. Asymptomatic women aged 40 and over should continue to receive a clinical breast examination as part of a periodic health examination preferably annually.

Perform Therapeutic Procedure

0.97

Key Recommendations by Diagnosis:Candidal Endocarditis Pericarditis Suppurative Phlebitis and Myocarditis:Both native valve and prosthetic valve infection should be managed with surgical replacement of the infected valve. Medical therapy with amphotericin B with or without flucytosine at maximal tolerated doses has most often been used.

Educate/Counsel

0.97

Guideline: Treatment Must Be Preceded by Thorough Counseling About the Nature of the Syndrome Its Natural History Its Extracolonic Manifestations and the Need for Compliance With Recommendations for Management and Surveillance.

Prepare

1

The panel recommends the following:Education of physicians dietitians nurses and the public about celiac disease by a trans-National Institutes of Health (NIH) initiative to be led by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) in association with the Centers for Disease Control and Prevention.

Practice Recommendations:Patient Empowerment and Education:Education is based on identified individual needs risk factors ulcer status available resources and ability to heal.

Prescribe

0.88

Recommendations:There is insufficient evidence to support or refute manual therapy biofeedback or Alexander technique in the treatment of PD.

Test

0.9

Assist in identifying multicentric and multifocal carcinomas in patients with tissue diagnosis of breast cancer.

Prepare

1

Fire Drills:Fire drills not only allow staff to practice for a fire but also help troubleshoot any difficulties that might occur. Some elements to consider in planning a fire drill are:The proper response of each surgical team member and the operating suite staff.How the patient can easily and safely be moved to another ORHow the spread of smoke should be prevented (for example through the use of smoke doors and air duct dampers).The location and operation of fire extinguishers fire alarm pull stations and exits.What the response of additional fire-fighting personnel (such as the fire response team and local fire department) should be.

Test

1

Radiologic Studies:It is recommended that an abdominal radiograph be performed in infants with clinical suspicion of NEC. The influences on infant outcome and diagnostic validity of the number of abdominal x-rays the type of view(s) or the frequency or timing of abdominal radiographs have not been systematically studied.

Prescribe

0.79

Women should be monitored for signs and symptoms of congestive heart failure during treatment with trastuzumab.

Test

0.89

At-risk adults and children are defined for the purpose of this guidance as those who are in at least one of the following groups.People who:Have chronic respiratory disease (including asthma and chronic obstructive pulmonary disease).Have significant cardiovascular disease (excluding people with hypertension only).Have chronic renal disease.Are immunocompromised.Have diabetes mellitus.Are aged 65 years or older.

Test

1

It is recommended that sputum Gram stain and culture on high quality specimens be considered when managing children with more severe disease. Note: A high quality sputum is usually defined by the presence of less than 10 squamous epithelial cells and greater than 25 white blood cells per low power field.

Conclude

1

Results and Recommendations:Are the circumstances surrounding cardiopulmonary resuscitation (CPR) predictive of outcome?Prognosis cannot be based on the circumstances of cardiopulmonary resuscitation.

Refer/Consult

1

Recommendation :Practitioners policy makers and commissioners should only endorse exercise referral schemes to promote physical activity that are part of a properly designed and controlled research study to determine effectiveness .Individuals should only be referred to schemes that are part of such a study.

Prescribe

0.83

Patients should be encouraged to enroll in randomized controlled trials comparing promising new treatments such as gemcitabine in combination with a fluoropyrimidine against other treatments with proven response.

Test

1

Clinical Evaluation:Women of childbearing age presenting to the ED with abdominal pain and/or vaginal bleeding will receive a urine test for pregnancy at triage .

Educate/Counsel

0.51

Clinical Evaluation:Women of childbearing age presenting to the ED with abdominal pain and/or vaginal bleeding will receive a urine test for pregnancy at triage .

Prescribe

0.31

Follow-Up:Patients should be informed that the rash and pruritus of scabies might persist for up to 2 weeks after treatment. Symptoms or signs that persist for >2 weeks can be attributed to several factors. Treatment failure might be caused by resistance to medication or by faulty application of topical scabicides. Patients with crusted scabies might have poor penetration into thick scaly skin and harbor mites in these difficult-to-penetrate layers. Particular attention must be given to the fingernails of these patients. Reinfection from family members or fomites might occur in the absence of appropriate contact treatment and washing of bedding and clothing. Even when treatment is successful and reinfection is avoided symptoms can persist or worsen as a result of allergic dermatitis. Finally household mites can cause symptoms to persist as a result of crossreactivity between antigens. Some specialists recommend re-treatment after 1-2 weeks for patients who are still symptomatic; others recommend re-treatment only if live mites are observed. Patients who do not respond to the recommended treatment should be re-treated with an alternative regimen.

Additional Considerations for HIV Screening::Communicating test results. The central goal of HIV screening in health-care settings is to maximize the number of persons who are aware of their HIV infection and receive care and prevention services. Definitive mechanisms should be established to inform patients of their test results.

Prescribe

0.99

Symptomatic patients with TCA poisoning might require prehospital interventions such as intravenous fluids cardiovascular agents and respiratory support in accordance with standard advanced cardiac life support (ACLS) guidelines as outlined by the American Heart Association.

Perform Therapeutic Procedure

1

Recommendation :Hand decontamination is the most important step in preventing nosocomial spread of respiratory syncytial virus (RSV). Hands should be decontaminated before and after direct contact with patients after contact with inanimate objects in the direct vicinity of the patient and after removing gloves.

Conclude

1

Patient Management Recommendations:Assess for fibrinolytic therapy in patients with symptoms suggestive of AMI and presenting within 12 hours of symptom onset if ECG reveals:1.New or presumably new right bundle branch block (RBBB).2.RBBB atypical BBB or ventricular paced and concordant ST-segment deviations greater than or equal to 0.1 mV (1 mm) towards the major QRS deflection or discordant ST-segment deviations greater than or equal to 0.5 mV (5 mm) away from the major QRS deflection in 2 or more contiguous leads.

Management of Sex Partners:Patients who have acute epididymitis confirmed or suspected to be caused by N. gonorrhoeae or C. trachomatis should be instructed to refer sex partners for evaluation and treatment if their contact with the index patient was within the 60 days preceding onset of the patient's symptoms.Patients should be instructed to avoid sexual intercourse until they and their sex partners are cured (i.e. until therapy is completed and patient and partners no longer have symptoms).

Test

1

Rectal Pharyngeal and Conjunctival Specimens Men and Women:Due to the emergence of rectal Lymphogranuloma venereum (LGV) infection in men who have sex with men (French Ison & Macdonald 2005) the current (2006) recommended method of detecting rectal LGV infection is to perform a rectal NAAT which if positive is sent to the Health Protection Authority for confirmation.

Educate/Counsel

0.96

The Discharge Planning Process:Clarify activity level and ability with a focus on safety and mobility.

Document

1

Step 6:Are the causes and consequences of the patient's dehydration or fluid/electrolyte imbalance to be treated? If it is decided to treat the causes of the patient's dehydration or fluid/electrolyte imbalance or to intervene to correct or prevent a fluid deficit or electrolyte imbalance proceed to Step 7.If the cause of the patient's dehydration is not clear continue to look for that cause while providing appropriate support and symptomatic management. If it is decided not to treat or intervene because the patient has a terminal or end-stage condition or because the patient or family has requested no intervention or for any other valid clinical reason document the reasons for this decision in the patient's medical record.

Perform Therapeutic Procedure

1

Arterial reconstructive surgery is a treatment option only in healthy individuals with recently acquired erectile dysfunction secondary to a focal arterial occlusion and in the absence of any evidence of generalized vascular disease .

Prepare

1

The Task Force recommends additional research in the following human model systems to define the clinical syndrome of androgen deficiency and to study the benefits and risks of androgen therapy .Surgical menopause is a condition in which the ovarian but not adrenal androgen precursors are removed abruptly independent of age.Hypopituitarism although uncommon can be used to study the physiological replacement of both ovarian androgens and adrenal androgen precursors.Anorexia nervosa may be used as a model of androgen deficiency secondary to dysfunction of the hypothalamic-pituitary and adrenal axes.Primary adrenal insufficiency allows for the investigation of the loss of adrenal androgen precursors in the presence of intact ovarian androgen function.Ablation-replacement models in normal women using GnRH analogs to eliminate ovarian androgens with or without suppression of adrenal androgen precursors offer another way to assess the effects of androgen withdrawal and replacement.Subjects with complete androgen insensitivity syndrome offer a way to investigate target tissue effects which are dependent on the androgen receptor but are independent of aromatization.There are studies in patients with low weight and HIV and with natural aging; however these systems are too complex to recommend as initial models to understand the potential therapeutic role of androgens in women.

Prevent

0.38

The Task Force recommends additional research in the following human model systems to define the clinical syndrome of androgen deficiency and to study the benefits and risks of androgen therapy .Surgical menopause is a condition in which the ovarian but not adrenal androgen precursors are removed abruptly independent of age.Hypopituitarism although uncommon can be used to study the physiological replacement of both ovarian androgens and adrenal androgen precursors.Anorexia nervosa may be used as a model of androgen deficiency secondary to dysfunction of the hypothalamic-pituitary and adrenal axes.Primary adrenal insufficiency allows for the investigation of the loss of adrenal androgen precursors in the presence of intact ovarian androgen function.Ablation-replacement models in normal women using GnRH analogs to eliminate ovarian androgens with or without suppression of adrenal androgen precursors offer another way to assess the effects of androgen withdrawal and replacement.Subjects with complete androgen insensitivity syndrome offer a way to investigate target tissue effects which are dependent on the androgen receptor but are independent of aromatization.There are studies in patients with low weight and HIV and with natural aging; however these systems are too complex to recommend as initial models to understand the potential therapeutic role of androgens in women.

Educate/Counsel

0.22

The Task Force recommends additional research in the following human model systems to define the clinical syndrome of androgen deficiency and to study the benefits and risks of androgen therapy .Surgical menopause is a condition in which the ovarian but not adrenal androgen precursors are removed abruptly independent of age.Hypopituitarism although uncommon can be used to study the physiological replacement of both ovarian androgens and adrenal androgen precursors.Anorexia nervosa may be used as a model of androgen deficiency secondary to dysfunction of the hypothalamic-pituitary and adrenal axes.Primary adrenal insufficiency allows for the investigation of the loss of adrenal androgen precursors in the presence of intact ovarian androgen function.Ablation-replacement models in normal women using GnRH analogs to eliminate ovarian androgens with or without suppression of adrenal androgen precursors offer another way to assess the effects of androgen withdrawal and replacement.Subjects with complete androgen insensitivity syndrome offer a way to investigate target tissue effects which are dependent on the androgen receptor but are independent of aromatization.There are studies in patients with low weight and HIV and with natural aging; however these systems are too complex to recommend as initial models to understand the potential therapeutic role of androgens in women.

There is no mortality difference between patients receiving early tracheostomy (3 to 7 days) and late tracheostomy or extended endotracheal intubation.

Prepare

0.57

There is no mortality difference between patients receiving early tracheostomy (3 to 7 days) and late tracheostomy or extended endotracheal intubation.

Perform Therapeutic Procedure

0.24

Facilitate opportunities for optimal quality of life within the full continuum of health-care and rehabilitation programs.

Prepare

1

Research is encouraged to identify methods to increase correct and consistent condom use by sexually active adolescents and to evaluate effectiveness of strategies to promote condom use including condom education and availability programs in schools.

Educate/Counsel

1

Items that have come in direct contact with the infected person's head should be washed in hot soapy water and dried with heat in order to eliminate the lice and nits. Use of insecticides or extraordinary cleaning measures in the person's environment are not indicated.

Prepare

1

It is recommended that all parent-training/education programmes whether group- or individual-based should:Be structured and have a curriculum informed by principles of social-learning theoryInclude relationship-enhancing strategiesOffer a sufficient number of sessions with an optimum of 8 to 12 to maximise the possible benefits for participantsEnable parents to identify their own parenting objectivesIncorporate role-play during sessions as well as homework to be undertaken between sessions to achieve generalisation of newly rehearsed behaviours to the home situationBe delivered by appropriately trained and skilled facilitators who are supervised have access to necessary ongoing professional development and are able to engage in a productive therapeutic alliance with parentsAdhere to the programme developer's manual and employ all of the necessary materials to ensure consistent implementation of the programme.

Test

1

For VLBW PT infants US should be used to predict long-term neurodevelopmental outcome. The findings of grades 3 and 4 intraventricular hemorrhage periventricular cystic lesions and moderate to severe ventriculomegaly are all associated with adverse outcome.

Perform Therapeutic Procedure

0.75

For VLBW PT infants US should be used to predict long-term neurodevelopmental outcome. The findings of grades 3 and 4 intraventricular hemorrhage periventricular cystic lesions and moderate to severe ventriculomegaly are all associated with adverse outcome.

Prescribe

0.24

Viscosupplementation may have a role in the treatment of knee pain due to osteoarthritis during the initial 12 weeks in the hands of physicians technically proficient in arthrocentesis.

Prescribe

0.94

Warfarin should be considered for use in stroke and TIA patients with non-valvular atrial fibrillation.

Prepare

0.73

Clinicians should be aware of the background incidence of endometrial cancer among users and non-users of HRT and in those who present with post-menopausal bleeding (PMB).

Monitor

0.94

Early Postoperative Management: Fluid and electrolyte management in elderly patients should be monitored regularly.

Monitor

1

Antepartum surveillance should be instituted once the possibility of extrauterine survival for the growth-restricted fetus has been determined. This may include Doppler velocimetry contraction stress testing nonstress test (NST) with amniotic fluid volume assessment and biophysical profile (BPP).

Health care professionals should be aware of the signs and symptoms of deep venous thrombosis and should perform physical assessment to detect this complication.

Educate/Counsel

0.98

Health Promotion StrategiesGeneral RecommendationsStress ManagementEducate women that feelings of anger and hostility can contribute to higher levels of cholesterol.

Prescribe

1

Provide stimulation clues such as pictures and signs .

Educate/Counsel

0.84

Regardless of the type of photoscreening system used the evaluator must know how to properly apply the technology and understand the limitations of the test such as the possible occurrence of false-positive and false-negative results as they apply to the population being tested.

At a minimum the end-points should be glycated hemoglobin (GHb) and frequency of hypoglycemic episodes. Ideally outcomes (e.g. long-term complications and hypoglycemia) should also be examined.

Refer/Consult

0.94

Electroencephalogram (EEG) It is recommended that patients with an apparent first unprovoked seizure be considered for neurologic evaluation after consultation between the parents and treating physician. Neurologic consultation may be more beneficial in situations where the diagnosis is equivocal after a thorough history and physical or in cases of persistent parental anxiety.

Prepare

0.99

Physicians should become knowledgeable about contemporaneous local referral center and national comparative data regarding survival and long-term outcomes associated with extremely preterm birth.

Test

1

The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening for cervical cancer in women who have been sexually active and have a cervix.

Prepare

0.88

Pediatricians should be familiar with the screening and counseling guidelines for disordered eating and other related behaviors.

Prepare

0.23

Pediatricians should be familiar with the screening and counseling guidelines for disordered eating and other related behaviors.

Perform Therapeutic Procedure

0.27

Organize and participate in the Memorial Service .

Prescribe

1

Carbohydrates For the neonate carbohydrate delivery in PN should begin at approximately 6 to 8 mg/kg per minute of dextrose and be advanced as tolerated to a goal of 10 to 14 mg/kg per minute.

Test

1

In patients suspected of having non-small cell lung cancer who have no evidence of distant metastases and who have normal mediastinal nodes by CT but in whom invasive staging of the mediastinum is recommended (because of a high FN rate of CT) mediastinoscopy is the invasive procedure of choice to rule out mediastinal node involvement. This recommendation is based on the ability of mediastinoscopy to stage most of the commonly involved mediastinal node stations with a low FN rate (approximately 10%) and low morbidity (2%; outpatient procedure). For these patients TBNA TTNA and EUS-NA are not recommended because of a high FN rate(approximately 10%) and low morbidity (2%; outpatient procedure).For the subset of these patients who have a left upper lobe cancer the Chamberlain procedure extended cervical mediastinoscopy or thoracoscopy should be additionally performed to evaluate the aortopulmonary window nodes.

Prepare

1

The infectious and transmissible nature of bacteria that cause early childhood caries and methods of oral health risk assessment anticipatory guidance and early intervention should be included in the curriculum of all pediatric medical residency programs and postgraduate continuing medical education curricula at an appropriate time.

None of the currently available pediculicides are 100% ovicidal and resistance has been reported with lindane pyrethrins and permethrin. Treatment failure does not equate with resistance and most instances of such failure represent misdiagnosis/misidentification or noncompliance with the treatment regimen.

Educate/Counsel

1

For patients with a current diagnosis of a sleep disorder documentation and continuation of ongoing treatments such as continuous positive airway pressure (CPAP) should be maintained and reinforced by patient and family education.

For patients with bone metastases external radiation therapy is indicated to control localized pain. Higher fractionated doses of external radiation therapy provide the most predictable and longer-lasting pain relief for bone metastases.

Prepare

1

Whenever conscious or deep sedation is required to perform any procedure the guidelines developed by the American Academy of Pediatrics for patient monitoring and resuscitative equipment should be followed.

Prescribe

1

Corticosteroid dosing in IBD should be kept to a minimum and other immunomodulatory agents should be considered to help withdraw patients from corticosteroids once corticosteroid dependence becomes evident.

Prescribe

1

Medical management may include initiating a two-week trial of topical antibiotics for clean pressure ulcers that are not healing or are continuing to produce exudate after two to four weeks of optimal patient care. The antibiotic should be effective against gram-negative gram-positive and anaerobic organisms.

Prescribe

1

Patients who have begun a course of treatment with efalizumab at the date of publication of this guidance should have the option of continuing to receive treatment until the patients and their clinicians consider it is appropriate to stop.

Perform Therapeutic Procedure

1

The addition of post-operative treatment using a combination of chemotherapy and radiotherapy has been shown to improve survival outcome for patients with tumour involvement of pelvic lymph nodes resection margins and/or parametrial tissue.

Prescribe

1

In anthracycline-resistant patients or patients who have previously received an anthracycline as adjuvant therapy:Either docetaxel (100 mg/m2 over one hour every three weeks) or paclitaxel (175 mg/m2 over three hours every three weeks) may be considered as a treatment option after failure of prior anthracycline treatment or in women whose disease is resistant to anthracyclines. The evidence supporting the use of single-agent docetaxel is more consistent and is based on a larger number of trials and patients than the evidence for paclitaxel.In selected patients the combination of docetaxel and capecitabine is a therapeutic option. Due to the toxicity of the combination patient selection for good performance status or younger age is recommended. It is recommended that capecitabine in the docetaxel/capecitabine combination be given at 75% of full dose.

Test

1

Consideration should be given to screening all HIV-infected men and women for gonorrhea and chlamydial infections. However because of the cost of screening and the variability of prevalence of these infections decisions about routine screening for these infections should be based on epidemiologic factors (including prevalence of infection in the community or the population being served) availability of tests and cost. (Some HIV specialists also recommend type-specific serologic testing for herpes simplex virus type 2 for both men and women.)

Monitor

0.96

The use of intra-oral devices should be monitored following initiation of therapy to allow device adjustment and assessment of OSAHS control and symptoms.

Prescribe

1

Although postmenopausal women with leiomyomas may have more bleeding problems and some increase in leiomyoma size while taking hormone replacement therapy there appears to be no reason to withhold this treatment option from women who desire or need such therapy.

Prevent

0.98

The following recommendations are based primarily on consensus and expert opinion (Level C): Epidural anesthesia appears to be safe in women taking unfractionated low-dose heparin if the APTT is normal.

Prescribe

1

Alternatives for prophylaxis for high-risk* patients undergoing gynecologic surgery especially for malignancy include:Pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory.Unfractionated heparin (5 000 U) administered 8 hours before surgery and continued postoperatively until discharge.Dalteparin (5 000 antifactor-Xa U) administered 12 hours before surgery and then once a day thereafter.Enoxaparin (40 mg) administered 12 hours before surgery and then once a day thereafter.

Test

1

The screening test generally should be performed on venous plasma or serum samples using well-calibrated and well-maintained laboratory instruments.

Prevent

0.95

If analgesia/anesthesia is required regional or neuraxial analgesia/anesthesia should be used because it is efficacious and safe for intrapartum management of women with severe preeclampsia in the absence of coagulopathy.

Test

0.99

All women with PCOS should be screened for dyslipidemia with a fasting lipoprotein profile including total cholesterol low-density lipoprotein (LDL) cholesterol high-density lipoprotein (HDL) cholesterol and triglyceride determinations.

Prepare

0.69

All women with PCOS should be screened for dyslipidemia with a fasting lipoprotein profile including total cholesterol low-density lipoprotein (LDL) cholesterol high-density lipoprotein (HDL) cholesterol and triglyceride determinations.

Advocate

0.31

Health care institutions should design their facilities to promote the philosophy of family-centered care. Pediatricians should advocate for opportunities for children and families to participate in design planning for renovation or construction of hospitals clinics and office-based practices.

Prepare

1

Pediatricians should support and implement the Standards for Child and Adolescent Immunization Practices as endorsed by the AAP and the National Vaccine Advisory Committee .

Educate/Counsel

0.59

Pediatricians should support and implement the Standards for Child and Adolescent Immunization Practices as endorsed by the AAP and the National Vaccine Advisory Committee .

Prescribe

0.21

Encourage support and protect breastfeeding.

Prescribe

1

Combination chemotherapy with cyclophosphamide doxorubicin vincristine and prednisone (CHOP) is recommended for patients with no apparent cardiac disease or significant comorbidity. Dose and schedule should be the same as that used in younger patients.

Prepare

0.31

Combination chemotherapy with cyclophosphamide doxorubicin vincristine and prednisone (CHOP) is recommended for patients with no apparent cardiac disease or significant comorbidity. Dose and schedule should be the same as that used in younger patients.

Educate/Counsel

0.69

Health practitioners providing care for Maori and Pacific Island peoples should be sensitive to their particular needs and encourage the use of a support person or advocate.

Prescribe

1

5.5% amorolfine (Loceryl)* applied once weekly for 15 months in combination with terbinafine (Lamasil) 250mg orally every day for 12 weeks is strongly supported as the most effective means of mycological and clinical cure for severe dermatophyte onychomycosis. In addition studies indicate combination therapy to be the most cost-effective means of treatment as compared to monotherapy.

Conclude

1

Clinical (nonendoscopic) stratification of patients into low- and high-risk categories for rebleeding and mortality is important for proper management. Available prognostic scales may be used to assist in decision-making. Early stratification of patients into low- and high-risk categories for rebleeding and mortality based on clinical and endoscopic criteria is important for proper management. Available prognostic scales may be used to assist in decision making.

Educate/Counsel

1

The endoscopic general surgeon should arrange to interview and examine the patient preoperatively and should participate with the spine surgeon in development of an operative plan. Special attention should be directed towards suitability of the patient for anesthesia and for the proposed endoscopic procedure. The endoscopic surgeon should not feel obligated to participate in any procedure that he/she does not feel is in the best interest of the patient. Risks and complications unique to the endoscopic access portion of the procedure should be identified and communicated to the patient at this time as well as the specific roles and responsibilities of the endoscopic general surgeon. The endoscopic general surgeon and spine surgeon should each communicate their individual experience in this procedure to the patient. This results in a true informed consent. Both co-surgeons must be named on the patient consent form.

Educate/Counsel

1

The risks and benefits of all treatment options should be discussed with the patient prior to any intervention. Patient and partner satisfaction is the primary target outcome for the treatment of PE.

Educate/Counsel

0.99

Evidence is lacking related to ventilator-associated pneumonia (VAP) and issues of heated versus unheated circuits type of heated humidifier method for filling the humidifier and technique for clearing condensate from the ventilator circuit. It is prudent to avoid excessive accumulation of condensate in the circuit. Care should be taken to avoid accidental drainage of condensate into the patient??s airway and to avoid contamination of caregivers during ventilator disconnection or during disposal of condensate. Care should be taken to avoid breaking the ventilator circuit which could contaminate the interior of the circuit .

Prescribe

1

For patients undergoing autologous stem cell transplantation as part of standard therapy it is recommended that the transplantation regimen include melphalan 200 mg/m2 without total body radiation.

Test

1

The initial laboratory investigation of ascitic fluid should include an ascitic fluid cell count and differential ascitic fluid total protein and serum-ascitic albumin gradient (SAAG).

Prescribe

1

Does early ADT improve outcomes over deferred therapy?Recommendation: Until data from studies using modern medical diagnostic and biochemical tests and standardized follow-up schedules become available no specific recommendations can be issued by the Panel regarding the question of early versus deferred ADT using LHRH agonists or orchiectomy. A discussion about the pros and cons of early versus deferred therapy should occur between patient and practitioner. Antiandrogen monotherapy is not recommended. Patients should be followed clinically and started on ADT once symptoms of locally progressive or metastatic disease present.

Prepare

1

Outcomes-based research should be performed on the effectiveness of various school-based mental health models that are designed to improve psychosocial and academic outcomes.

Prescribe

1

On the basis of evidence from a single Class I study and a few Class II or III studies it appears that mitoxantrone may have a beneficial effect on disease progression in patients with multiple sclerosis (MS) whose clinical condition is deteriorating . In general however this agent is of limited use and of potentially great toxicity. Therefore it should be reserved for patients with rapidly advancing disease who have failed other therapies.

Refer/Consult

0.99

PAH patients with New York Heart Association (NYHA) functional class III and IV symptoms should be referred to a transplant center for evaluation and listing for LT or heart-lung transplantation (HLT).

Conclude

0.6

PAH patients with New York Heart Association (NYHA) functional class III and IV symptoms should be referred to a transplant center for evaluation and listing for LT or heart-lung transplantation (HLT).

Prescribe

0.4

The selection of patients for radiopharmaceutical therapy should consider the patient??s marrow function performance status recent use of other marrow suppression agents (chemotherapy or radiotherapy) unsuitability for alternate palliative interventions (wide field or local field radiotherapy hormone therapy chemotherapy bisphosphonates) and anticipated life expectancy.

Prescribe

1

In antithrombin-deficient women compound heterozygotes for prothrombin G20210A and factor V Leiden and homozygotes for these conditions with a history of VTE the guideline developers suggest intermediate-dose LMWH prophylaxis or moderate-dose UFH .

Monitor

0.83

Check the adolescent annually for scoliosis and kyphosis.

Refer/Consult

0.94

Oral and primary health care providers should work together to provide diagnoses observation and management of any lesions that disrupt the integrity of the oral mucosa in children.

Prescribe

1

The full series should be given (initial dose and a second dose 6 to 12 months later) to ensure maximal antibody response.

Monitor

0.23

The full series should be given (initial dose and a second dose 6 to 12 months later) to ensure maximal antibody response.

The combination of paclitaxel (Taxol) or docetaxel (Taxotere) with cisplatin can be recommended as one of a number of chemotherapy options in the first-line therapy of patients with advanced non-small cell lung cancer and a good performance status.

Prepare

1

In reaching a decision as to whether to add newborn screening for CF states should consider available state resources and priorities as well as available national guidelinesregarding CF screening diagnosis and treatment.

Perform Therapeutic Procedure

0.67

In reaching a decision as to whether to add newborn screening for CF states should consider available state resources and priorities as well as available national guidelinesregarding CF screening diagnosis and treatment.

Nursing best practice guidelines can be successfully implemented only where there are adequate planning resources organizational and administrative support as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes:An assessment of organizational readiness and barriers to educationInvolvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation processDedication of a qualified individual to provide the support needed for the education and implementation processOngoing opportunities for discussion and education to reinforce the importance of best practicesOpportunities for reflection on personal and organizational experience in implementing guidelines

Educate/Counsel

0.67

Patient's and carer's perceptions and expectations of PEG feeding should be taken into account and the benefits risks and burden of care fully explained before initiating feeding.

Prescribe

1

Studies have not adequately defined the role of most adjunctive therapies for diabetic foot infections but systematic reviews suggest that granulocyte colony-stimulating factors and systemic hyperbaric oxygen therapy may help prevent amputations . These treatments may be useful for severe infections or for those that have not adequately responded to therapy despite correcting for all amenable local and systemic adverse factors

Refer/Consult

0.96

Recommending nPEP For Sexual Assault Survivors: Starter packs of medication should be available on-site for rapid initiation of nPEP following sexual assault. Arrangements should be made to ensure that the patient receives a continued supply of medication and is referred to an HIV specialist.

Educate/Counsel

1

Clinicians should inform and advise HIV-infected substance users chronically infected with hepatitis B (or co-infected with hepatitis B and C) that sharing injection equipment and engaging in unprotected sex place their partners at risk for transmission of both HIV and viral hepatitis.

Refer/Consult

0.97

Children and adolescents who are sexually assaulted should be managed in an emergency department or other setting where appropriate resources are available to address the medical psychosocial and legal issues of such an offense.

Advocate

0.99

Basic life support training for the aforementioned groups should be advocated in policy advisory discussions at all governmental levels with a goal of making the training readily available and affordable.

Prescribe

1

Intravenous narcotics by divided doses or demand modalities may be used as initial management for lower risk patients presenting with stable and adequate pulmonary performance as long as the desired clinical response is achieved.

Prescribe

0.99

Ibuprofen is effective and should be considered for the acute treatment of migraine in children.

Monitor

1

When the patient's level of consciousness is minimally depressed and verbal communication can be continually monitored pulse oximetry may not be necessary.Consider capnometry to provide additional information regarding early identification of hypoventilation.

Prescribe

1

Botulinum toxin injections may be used for anal fissures that fail to respond to conservative measures and have been associated with a healing rate superior to placebo. There is inadequate consensus on dosage precise site of administration number of injections or efficacy.

Prepare

0.91

Clinicians working in juvenile justice settings must be vigilant for personal safety and security issues and aware of actions that may compromise their safety and/or the safety and containment of the incarcerated youth .

Inquire

1

Gather information on:The amount type and time of daily fluid intake paying particular attention to the intake amount of caffeine and alcoholThe frequency nature and consistency of bowel movementsAny relevant medical or surgical history which may be related to the incontinence problem such as but not limited to diabetes stroke Parkinson's disease heart failure recurrent urinary tract infections or previous bladder surgery

Prepare

0.9

.Interventions for encouraging substance-free competition should be developed that are more positive than punitive such as programs that teach sound nutrition and training practices along with skills to resist the social pressures to use performance-enhancing substances.

Prepare

0.97

Organizations establish a corporate policy for least restraint that includes components of physical and chemical restraints.

Conclude

0.73

Consider a medical and rehabilitative approach to initial treatment in most instances of nontraumatic upper limb injury among individuals with SCI.

Prescribe

0.84

Erythropoietin is recommended as a safe and effective treatment option if given with the intent of reducing the incidence of symptomatic treatment-related anemia and the need for red blood cell transfusion.